Healthcare Provider Details

I. General information

NPI: 1588376800
Provider Name (Legal Business Name): FMC MEDICAL CLINIC - BERRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 SCHOOL AVE
BERRY AL
35546-2246
US

IV. Provider business mailing address

3901 GREENSBORO AVE STE A
TUSCALOOSA AL
35405-3771
US

V. Phone/Fax

Practice location:
  • Phone: 205-689-0909
  • Fax:
Mailing address:
  • Phone: 205-759-6165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL CLAY CONVILLE
Title or Position: CORP DIRECTOR, PHYSICIAN SERVICES
Credential:
Phone: 205-759-6165