Provider Demographics
NPI:1831353846
Name:JASPER DOCTORS CLINIC AND URGENT CARE INC.
Entity type:Organization
Organization Name:JASPER DOCTORS CLINIC AND URGENT CARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BOLANLE
Authorized Official - Middle Name:O
Authorized Official - Last Name:GBADEBO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-295-0002
Mailing Address - Street 1:4330 HIGHWAY 78 E STE 115
Mailing Address - Street 2:MEDICAL PLAZA EAST 114-115
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-8955
Mailing Address - Country:US
Mailing Address - Phone:205-295-0002
Mailing Address - Fax:205-295-0991
Practice Address - Street 1:4330 HIGHWAY 78 E STE 115
Practice Address - Street 2:MEDICAL PLAZA EAST 114-115
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-8955
Practice Address - Country:US
Practice Address - Phone:205-295-0002
Practice Address - Fax:205-295-0991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-18
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMEDICAID 102173207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty