Healthcare Provider Details

I. General information

NPI: 1811288038
Provider Name (Legal Business Name): SOUTH ALABAMA MEDICAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2011
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date: 07/23/2024
Reactivation Date: 07/31/2024

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 Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number1-072232
License Number StateAL
# 5
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateAL

VIII. Authorized Official

Name: BRIDGOT PETERS
Title or Position: DIRECTOR
Credential:
Phone: 251-445-7618