Healthcare Provider Details

I. General information

NPI: 1407976624
Provider Name (Legal Business Name): DODGE CITY MEDICAL CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 12/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

561 AL HIGHWAY 69 S SUITE B
HANCEVILLE AL
35077-3403
US

IV. Provider business mailing address

PO BOX 1208
CULLMAN AL
35056-1208
US

V. Phone/Fax

Practice location:
  • Phone: 256-287-2345
  • Fax:
Mailing address:
  • Phone: 256-287-2345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberMD27216
License Number StateAL

VIII. Authorized Official

Name: RICHARD ANTHONY BUCCO JR.
Title or Position: PRESIDENT
Credential: MD, PHD
Phone: 256-287-2345