Healthcare Provider Details

I. General information

NPI: 1033649298
Provider Name (Legal Business Name): CANTWELL FAMILY PSYCHIATRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 01/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 MIDDLE ST
FAIRHOPE AL
36532-1766
US

IV. Provider business mailing address

PO BOX 392
FAIRHOPE AL
36533-0392
US

V. Phone/Fax

Practice location:
  • Phone: 251-517-5800
  • Fax: 251-517-5801
Mailing address:
  • Phone: 251-517-5800
  • Fax: 251-517-5801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number28950
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN JOSEPH BRODERICK-CANTWELL
Title or Position: OWNER
Credential: MD
Phone: 251-517-5800