Provider Demographics
NPI:1902095565
Name:TRAVIS CLINIC
Entity type:Organization
Organization Name:TRAVIS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WAVERLY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BEDSOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-289-9408
Mailing Address - Street 1:PO BOX 1159
Mailing Address - Street 2:
Mailing Address - City:DEMOPOLIS
Mailing Address - State:AL
Mailing Address - Zip Code:36732-1159
Mailing Address - Country:US
Mailing Address - Phone:334-289-9408
Mailing Address - Fax:334-289-1160
Practice Address - Street 1:312 US HWY 80 E # 3
Practice Address - Street 2:
Practice Address - City:DEMOPOLIS
Practice Address - State:AL
Practice Address - Zip Code:36732-3619
Practice Address - Country:US
Practice Address - Phone:334-289-9408
Practice Address - Fax:334-289-1160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2025-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11061207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
51082149OtherBLUE CROSS BLUE SHIELD
AL000082149Medicaid
51082149OtherBLUE CROSS BLUE SHIELD