Provider Demographics
NPI:1356799076
Name:SPANISH FORT INTERNAL MEDICINE, P C
Entity type:Organization
Organization Name:SPANISH FORT INTERNAL MEDICINE, P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:C
Authorized Official - Last Name:SYKORA
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:251-929-3058
Mailing Address - Street 1:7552 SPANISH FORT BLVD
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORT
Mailing Address - State:AL
Mailing Address - Zip Code:36527
Mailing Address - Country:US
Mailing Address - Phone:251-929-3058
Mailing Address - Fax:
Practice Address - Street 1:7552 SPANISH FORT BLVD
Practice Address - Street 2:
Practice Address - City:SPANISH FORT
Practice Address - State:AL
Practice Address - Zip Code:36527
Practice Address - Country:US
Practice Address - Phone:251-929-3058
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL30706174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1629208277Medicare PIN