Provider Demographics
NPI:1982805149
Name:DECATUR FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:DECATUR FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:DRAKE
Authorized Official - Last Name:RADCLIFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-584-8211
Mailing Address - Street 1:1215 7TH STREET SE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-3381
Mailing Address - Country:US
Mailing Address - Phone:256-306-1655
Mailing Address - Fax:256-306-1601
Practice Address - Street 1:1215 7TH STREET SE
Practice Address - Street 2:SUITE 110
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-3381
Practice Address - Country:US
Practice Address - Phone:256-306-1655
Practice Address - Fax:256-306-1601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529902310Medicaid
ALH409Medicare PIN
AL1982805149Medicare PIN