MEDICARE: SOUTH DEKALB FAMILY MEDICAL ASSOCIATES 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538487020
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH DEKALB FAMILY MEDICAL ASSOCIATES P.C.

Provider Business Mailing Address
First Line	:	15239 AL HIGHWAY 68 W
Second Line	:
City	:	CROSSVILLE
State	:	AL
Zip	:	35962-0158
Country	:	US
Telephone Number	:	256-528-7173
Fax Number	:	256-528-2425

Provider Business Practice Location Address
First Line	:	15239 AL HWY 68 W
Second Line	:
City	:	CROSSVILLE
State	:	AL
Zip	:	35962-0158
Country	:	US
Telephone Number	:	256-528-7173
Fax Number	:	256-528-2425

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	JENNIE MILLER
Credential	:
Telephone Number	:	256-505-4532

Provider Enumeration Date	:	05/10/2010
Last Update Date	:	06/10/2010

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