Healthcare Provider Details

I. General information

NPI: 1386984649
Provider Name (Legal Business Name): MIDWAY MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2013
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27550 STATE HIGHWAY 75 STE 105
ONEONTA AL
35121-3204
US

IV. Provider business mailing address

PO BOX 568
ONEONTA AL
35121-0007
US

V. Phone/Fax

Practice location:
  • Phone: 256-451-1250
  • Fax:
Mailing address:
  • Phone: 256-451-1250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateAL

VIII. Authorized Official

Name: MR. MUHAMMAD EJAZ ATA
Title or Position: OWNER
Credential: MD
Phone: 256-599-7566