Healthcare Provider Details

I. General information

NPI: 1700615846
Provider Name (Legal Business Name): RANDALL SCOTT CHURCHWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2022 2ND AVE E
ONEONTA AL
35121-2731
US

IV. Provider business mailing address

1500 1ST AVE N UNIT 3
BIRMINGHAM AL
35203-1866
US

V. Phone/Fax

Practice location:
  • Phone: 205-625-3650
  • Fax: 205-625-3638
Mailing address:
  • Phone: 205-545-5088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-105436
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: