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General NPI Number Information
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NPI Number | 1588141063
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Entity Type | Organization
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Legal Business Name | FMC MEDICAL CLINIC - FAYETTE LLC
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Dates
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Enumeration Date | 07/26/2018
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Last Update Date | 10/16/2024
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Provider Practice Location Address
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Address Line | 1653 TEMPLE AVE N STE 1
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City | FAYETTE
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State | AL
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Zip | 35555-1314
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Country | US
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Telephone | 205-932-1112
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Fax |
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Provider Business Mailing Address
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Address Line | 1653 TEMPLE AVE N STE 1
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City | FAYETTE
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State | AL
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Zip | 35555-1314
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Country | US
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Telephone | 205-932-1421
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Fax | 205-932-1428
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Authorized Official
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Title or Position | CORP DIRECTOR PHYSICIAN SERVICES
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Name | MR. DANIEL CLAY CONVILLE
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Credential |
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Telephone | 205-759-6165
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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 |
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License Number State |
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