Healthcare Provider Details

I. General information

NPI: 1023358660
Provider Name (Legal Business Name): SOUTHEASTERN MEDICAL MANAGEMENT ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2013
Last Update Date: 08/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6713 OLD LEEDS RD
MONTGOMERY AL
36117-2407
US

IV. Provider business mailing address

PO BOX 241983
MONTGOMERY AL
36124-1983
US

V. Phone/Fax

Practice location:
  • Phone: 334-300-9618
  • Fax:
Mailing address:
  • Phone: 334-300-9618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number9116005205
License Number StateAL

VIII. Authorized Official

Name: SHANNON SNELL
Title or Position: OWNER
Credential:
Phone: 334-300-9618