Healthcare Provider Details

I. General information

NPI: 1164743068
Provider Name (Legal Business Name): CULLMAN PRIMARY CARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2010
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 AL HIGHWAY 157 STE 100
CULLMAN AL
35058
US

IV. Provider business mailing address

503 CLARK ST NE
CULLMAN AL
35055-1921
US

V. Phone/Fax

Practice location:
  • Phone: 256-739-4131
  • Fax: 256-739-6027
Mailing address:
  • Phone: 256-739-0801
  • Fax: 256-739-0027

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: MRS. CONNIE BLANKENSHIP
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 256-739-0801