Healthcare Provider Details

I. General information

NPI: 1073035051
Provider Name (Legal Business Name): FORT PAYNE CLINIC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13280 COUNTY ROAD 51
COLLINSVILLE AL
35961-4174
US

IV. Provider business mailing address

PO BOX 11136
BELFAST ME
04915-4002
US

V. Phone/Fax

Practice location:
  • Phone: 307-782-7560
  • Fax:
Mailing address:
  • Phone: 565-249-9080
  • Fax: 256-524-9711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateAL
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAURA J FEY
Title or Position: SR. DIRECTOR PHYSICIAN REV CYCLE
Credential:
Phone: 615-221-3641