=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578183190
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLEGRA HEALTHCARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2020
-----------------------------------------------------
Last Update Date | 09/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1116 MITT LARY RD
-----------------------------------------------------
City | NORTHPORT
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35475-4978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-556-5634
-----------------------------------------------------
Fax | 205-556-5644
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1116 MITT LARY RD
-----------------------------------------------------
City | NORTHPORT
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35475-4978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-556-5634
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE-PRESIDENT
-----------------------------------------------------
Name | MRS. AMY MCMURRY SHIRLEY
-----------------------------------------------------
Credential | CRNP
-----------------------------------------------------
Telephone | 205-556-5634
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------