Provider Demographics
NPI:1720102387
Name:DRS. KETCHAM AND DISMUKES
Entity Type:Organization
Organization Name:DRS. KETCHAM AND DISMUKES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:SMITH
Authorized Official - Last Name:MAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-289-0499
Mailing Address - Street 1:202 HWY 80 E
Mailing Address - Street 2:P.O. BOX 650
Mailing Address - City:DEMOPOLIS
Mailing Address - State:AL
Mailing Address - Zip Code:36732
Mailing Address - Country:US
Mailing Address - Phone:334-289-0499
Mailing Address - Fax:334-289-3013
Practice Address - Street 1:202 HWY 80 E
Practice Address - Street 2:
Practice Address - City:DEMOPOLIS
Practice Address - State:AL
Practice Address - Zip Code:36732
Practice Address - Country:US
Practice Address - Phone:334-289-0499
Practice Address - Fax:334-289-3013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2802207Q00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000088680Medicaid
AL0110356OtherUNITED HEALTHCARE
AL000088681Medicaid
AL0110247OtherUNITED HEALTH CARE
AL051088680OtherBLUE CROSS BLUE SHIELD
AL051088681OtherBLUE CROSS BLUE SHIELD
AL0110356OtherUNITED HEALTHCARE
AL000088680Medicare PIN
AL=========OtherCHAMPUS TRICARE
AL0453490001Medicare NSC
ALC72471Medicare UPIN
AL0110356OtherUNITED HEALTHCARE
AL051088681OtherBLUE CROSS BLUE SHIELD