Provider Demographics
NPI:1750347142
Name:FITZ-GERALD & PERRET CLINIC
Entity type:Organization
Organization Name:FITZ-GERALD & PERRET CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MACK
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZ-GERALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-289-1517
Mailing Address - Street 1:203 HWY 80 WEST
Mailing Address - Street 2:P. O. BOX 935
Mailing Address - City:DEMOPOLIS
Mailing Address - State:AL
Mailing Address - Zip Code:36732
Mailing Address - Country:US
Mailing Address - Phone:334-289-1517
Mailing Address - Fax:334-289-8353
Practice Address - Street 1:203 HWY 80 WEST
Practice Address - Street 2:
Practice Address - City:DEMOPOLIS
Practice Address - State:AL
Practice Address - Zip Code:36732
Practice Address - Country:US
Practice Address - Phone:334-289-1517
Practice Address - Fax:334-289-8353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529302040Medicaid
AL529302040Medicaid