MEDICARE: SOUTHCARE CLINIC, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	18641	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	98764	OTHER	AL	BCBS
2	98764	OTHER	AL	NAMCI

General Provider Information

NPI Number	:	1316034911
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHCARE CLINIC, P.C.

Provider Business Mailing Address
First Line	:	11220 MEMORIAL PKWY SW
Second Line	:	SUITE AB
City	:	HUNTSVILLE
State	:	AL
Zip	:	35803-4415
Country	:	US
Telephone Number	:	256-880-5818
Fax Number	:	256-883-5346

Provider Business Practice Location Address
First Line	:	11220 MEMORIAL PKWY SW
Second Line	:	SUITE AB
City	:	HUNTSVILLE
State	:	AL
Zip	:	35803-4415
Country	:	US
Telephone Number	:	256-880-5818
Fax Number	:	256-883-5346

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SAMUEL J. RIBIS
Credential	:	M.D.
Telephone Number	:	256-880-5818

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	01/27/2009

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Directions to “SOUTHCARE CLINIC, P.C. ” Practice Location

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