Healthcare Provider Details

I. General information

NPI: 1962511600
Provider Name (Legal Business Name): SOUTHERN FAMILY MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 08/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2367 US HWY 431
BOAZ AL
35957
US

IV. Provider business mailing address

PO BOX 1290
BOAZ AL
35957
US

V. Phone/Fax

Practice location:
  • Phone: 256-840-4571
  • Fax: 256-840-4534
Mailing address:
  • Phone: 256-840-4571
  • Fax: 256-840-4534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number00025564
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0025564
License Number StateAL

VIII. Authorized Official

Name: ANGELA L CLIFTON
Title or Position: OWNER
Credential: MD
Phone: 256-891-7171