Healthcare Provider Details

I. General information

NPI: 1609879220
Provider Name (Legal Business Name): CULLMAN COUNTY MEDICAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 CHEROKEE AVE SW
CULLMAN AL
35055-5502
US

IV. Provider business mailing address

1910 CHEROKEE AVE. SW
CULLMAN AL
35055
US

V. Phone/Fax

Practice location:
  • Phone: 256-739-3500
  • Fax: 256-736-1093
Mailing address:
  • Phone: 256-739-3500
  • Fax: 256-775-6119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHANA JOCHUM HICE
Title or Position: DIRECTOR, PHYSICIAN PRACTICES
Credential:
Phone: 256-736-5328