Healthcare Provider Details

I. General information

NPI: 1245398304
Provider Name (Legal Business Name): FAMILY MEDICINE OF SARDIS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 SARDIS DR
SARDIS CITY AL
35956-2139
US

IV. Provider business mailing address

PO BOX 1049
BOAZ AL
35957-2201
US

V. Phone/Fax

Practice location:
  • Phone: 256-593-9999
  • Fax: 256-593-9141
Mailing address:
  • Phone: 256-593-9999
  • Fax: 256-593-9141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO779
License Number StateAL

VIII. Authorized Official

Name: DR. EVAN MICHAEL JOHNSON
Title or Position: PRESIDENT, OWNER
Credential: D.O.
Phone: 256-593-9999