Healthcare Provider Details

I. General information

NPI: 1912284852
Provider Name (Legal Business Name): IMC-EASTERN SHORE ADULT MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2011
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 GREENO RD S SUITE B
FAIRHOPE AL
36532-1905
US

IV. Provider business mailing address

300 GREENO RD S STE B
FAIRHOPE AL
36532-1905
US

V. Phone/Fax

Practice location:
  • Phone: 251-929-3424
  • Fax: 251-929-3430
Mailing address:
  • Phone: 251-929-3424
  • Fax: 251-929-3430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: PHILLIP L COWART
Title or Position: VP FINANCE
Credential:
Phone: 251-435-1361