MEDICARE: PANACEA O'NEILL MEDICAL GROUP INC

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

General Provider Information

NPI Number	:	1356870398
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PANACEA O'NEILL MEDICAL GROUP INC

Provider Business Mailing Address
First Line	:	104 SPENRYN DR
Second Line	:
City	:	MADISON
State	:	AL
Zip	:	35758-1890
Country	:	US
Telephone Number	:	256-772-4300
Fax Number	:	256-772-4302

Provider Business Practice Location Address
First Line	:	104 SPENRYN DR
Second Line	:
City	:	MADISON
State	:	AL
Zip	:	35758-1890
Country	:	US
Telephone Number	:	256-772-4300
Fax Number	:	256-772-4302

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	TIERNAN O'NEILL
Credential	:
Telephone Number	:	256-772-4300

Provider Enumeration Date	:	06/05/2017
Last Update Date	:	07/21/2022

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