Provider Demographics
NPI:1912300641
Name:BULLOCK PREVENTIVE AND FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:BULLOCK PREVENTIVE AND FAMILY MEDICINE, LLC
Other - Org Name:FOCUS-MD AL 1017, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:205-987-4044
Mailing Address - Street 1:430 EMERY DR
Mailing Address - Street 2:SUITE 700
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-4587
Mailing Address - Country:US
Mailing Address - Phone:205-987-4044
Mailing Address - Fax:
Practice Address - Street 1:430 EMERY DR
Practice Address - Street 2:SUITE 700
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-4587
Practice Address - Country:US
Practice Address - Phone:205-987-4044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-08
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO729207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty