Healthcare Provider Details

I. General information

NPI: 1891897948
Provider Name (Legal Business Name): TRICOUNTY FAMILY PRACTICE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 12/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 CHESTNUT ST
ROANOKE AL
36274-1301
US

IV. Provider business mailing address

149 CHESTNUT ST
ROANOKE AL
36274-1301
US

V. Phone/Fax

Practice location:
  • Phone: 334-863-5484
  • Fax: 334-863-5481
Mailing address:
  • Phone: 334-863-5484
  • Fax: 334-863-5481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20466
License Number StateAL

VIII. Authorized Official

Name: DR. ABAYOMI G OSHINOWO
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 334-863-5484