Healthcare Provider Details

I. General information

NPI: 1578863213
Provider Name (Legal Business Name): WOODSTOCK FAMILY MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2010
Last Update Date: 08/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28921 HIGHWAY 5
WOODSTOCK AL
35188-3613
US

IV. Provider business mailing address

28921 HIGHWAY 5
WOODSTOCK AL
35188-3613
US

V. Phone/Fax

Practice location:
  • Phone: 205-938-9348
  • Fax:
Mailing address:
  • Phone: 205-938-9348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20185
License Number StateAL

VIII. Authorized Official

Name: KAREN BALLARD-MONTGOMERY
Title or Position: PRESIDENT
Credential: MD
Phone: 205-938-9348