Healthcare Provider Details

I. General information

NPI: 1588141063
Provider Name (Legal Business Name): FMC MEDICAL CLINIC - FAYETTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 TEMPLE AVE N STE 1
FAYETTE AL
35555-1314
US

IV. Provider business mailing address

1653 TEMPLE AVE N STE 1
FAYETTE AL
35555-1314
US

V. Phone/Fax

Practice location:
  • Phone: 205-932-1112
  • Fax:
Mailing address:
  • Phone: 205-932-1421
  • Fax: 205-932-1428

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: MR. DANIEL CLAY CONVILLE
Title or Position: CORP DIRECTOR PHYSICIAN SERVICES
Credential:
Phone: 205-759-6165