Provider Demographics
NPI:1356567721
Name:FUNCTIONAL MEDICINE OF ALABAMA, PC
Entity type:Organization
Organization Name:FUNCTIONAL MEDICINE OF ALABAMA, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:ST. PETERY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:205-593-4200
Mailing Address - Street 1:2228 CAHABA VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242
Mailing Address - Country:US
Mailing Address - Phone:205-593-4200
Mailing Address - Fax:205-672-1009
Practice Address - Street 1:2228 CAHABA VALLEY DR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242
Practice Address - Country:US
Practice Address - Phone:205-593-4200
Practice Address - Fax:205-672-1009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO-797207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-27516OtherBCBS
ALK374OtherMEDICARE GROUP #
ALK374OtherMEDICARE GROUP #