Healthcare Provider Details

I. General information

NPI: 1386912723
Provider Name (Legal Business Name): SOUTH ALABAMA MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10075 GRAND BAY WILMER RD S
GRAND BAY AL
36541-5003
US

IV. Provider business mailing address

10075 GRAND BAY WILMER RD S
GRAND BAY AL
36541-5003
US

V. Phone/Fax

Practice location:
  • Phone: 251-865-1852
  • Fax: 251-865-1854
Mailing address:
  • Phone: 251-865-1852
  • Fax: 251-865-1854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRIDGOT PETERS
Title or Position: DIRECTOR
Credential:
Phone: 251-865-1852