Healthcare Provider Details

I. General information

NPI: 1063871184
Provider Name (Legal Business Name): FMC MEDICAL CLINIC MILLPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 06/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13530 HIGHWAY 96
MILLPORT AL
35576-2522
US

IV. Provider business mailing address

1820 RICE MINE RD N SUITE 200
TUSCALOOSA AL
35406-3281
US

V. Phone/Fax

Practice location:
  • Phone: 205-662-3207
  • Fax: 205-333-4660
Mailing address:
  • Phone: 205-333-4661
  • Fax: 205-333-4660

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. RYAN CAMPBELL
Title or Position: DIRECTOR OF PHYSICIAN SERVICE
Credential:
Phone: 205-759-6165