Healthcare Provider Details

I. General information

NPI: 1568571602
Provider Name (Legal Business Name): FAMILY PRACTICE OF JACKSONVILLE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1881 HWY 21 SOUTH
JACKSONVILLE AL
36265
US

IV. Provider business mailing address

PO BOX 777 1881 HWY 21 SOUTH
JACKSONVILLE AL
36265
US

V. Phone/Fax

Practice location:
  • Phone: 256-435-3035
  • Fax: 256-435-9111
Mailing address:
  • Phone: 256-435-3035
  • Fax: 256-435-9111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number7306
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7306
License Number StateAL

VIII. Authorized Official

Name: KEWAL K VERMA
Title or Position: PRESIDENT
Credential: MD
Phone: 256-435-3035