Healthcare Provider Details

I. General information

NPI: 1063879187
Provider Name (Legal Business Name): ALBANY INTERNAL MEDICINE LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2016
Last Update Date: 01/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 OSLER CT
ALBANY GA
31707-0205
US

IV. Provider business mailing address

2402 OSLER CT
ALBANY GA
31707-0205
US

V. Phone/Fax

Practice location:
  • Phone: 229-438-3302
  • Fax: 229-438-3384
Mailing address:
  • Phone: 229-438-3302
  • Fax: 229-438-3384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. BRUCE ALAN TRICKEL
Title or Position: ADMINISTRATOR
Credential: CMPE
Phone: 229-438-3368