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General NPI Number Information
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NPI Number | 1568571602
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Entity Type | Organization
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Legal Business Name | FAMILY PRACTICE OF JACKSONVILLE PC
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Dates
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Enumeration Date | 08/30/2006
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Last Update Date | 04/22/2008
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Provider Practice Location Address
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Address Line | 1881 HWY 21 SOUTH
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City | JACKSONVILLE
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State | AL
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Zip | 36265
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Country | US
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Telephone | 256-435-3035
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Fax | 256-435-9111
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Provider Business Mailing Address
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Address Line | PO BOX 777 1881 HWY 21 SOUTH
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City | JACKSONVILLE
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State | AL
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Zip | 36265
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Country | US
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Telephone | 256-435-3035
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Fax | 256-435-9111
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Authorized Official
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Title or Position | PRESIDENT
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Name | KEWAL K VERMA
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Credential | MD
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Telephone | 256-435-3035
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 7306
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License Number State | AL
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Taxonomy #2
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number | 7306
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License Number State | AL
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