Healthcare Provider Details

I. General information

NPI: 1720009962
Provider Name (Legal Business Name): MONTEVALLO FAMILY MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 SALEM RD SUITE 1
MONTEVALLO AL
35115-3586
US

IV. Provider business mailing address

33 SALEM RD SUITE 1
MONTEVALLO AL
35115-3586
US

V. Phone/Fax

Practice location:
  • Phone: 205-665-7991
  • Fax: 205-665-2913
Mailing address:
  • Phone: 205-665-7991
  • Fax: 205-665-2913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21192
License Number StateAL

VIII. Authorized Official

Name: MR. JONATHAN C. MERKLE
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 205-665-7991