Provider Demographics
NPI:1720009962
Name:MONTEVALLO FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:MONTEVALLO FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MERKLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-665-7991
Mailing Address - Street 1:33 SALEM RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MONTEVALLO
Mailing Address - State:AL
Mailing Address - Zip Code:35115-3586
Mailing Address - Country:US
Mailing Address - Phone:205-665-7991
Mailing Address - Fax:205-665-2913
Practice Address - Street 1:33 SALEM RD
Practice Address - Street 2:SUITE 1
Practice Address - City:MONTEVALLO
Practice Address - State:AL
Practice Address - Zip Code:35115-3586
Practice Address - Country:US
Practice Address - Phone:205-665-7991
Practice Address - Fax:205-665-2913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21192207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529911870Medicaid
AL51517997Medicaid
AL51517997Medicaid
ALG96107Medicare UPIN