Healthcare Provider Details

I. General information

NPI: 1790840775
Provider Name (Legal Business Name): BOAZ FAMILY MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 N SNEAD ST
BOAZ AL
35957-1763
US

IV. Provider business mailing address

122 N SNEAD ST
BOAZ AL
35957-1763
US

V. Phone/Fax

Practice location:
  • Phone: 256-840-5800
  • Fax: 256-840-5600
Mailing address:
  • Phone: 256-840-5800
  • Fax: 256-840-5600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberDO287
License Number StateAL

VIII. Authorized Official

Name: DR. JERRY RUSSELL ROBINSON
Title or Position: PHYSICIAN
Credential: D. O.
Phone: 256-840-5800