Provider Demographics
NPI:1033649298
Name:CANTWELL FAMILY PSYCHIATRY, LLC
Entity type:Organization
Organization Name:CANTWELL FAMILY PSYCHIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BRODERICK-CANTWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-517-5800
Mailing Address - Street 1:PO BOX 392
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36533-0392
Mailing Address - Country:US
Mailing Address - Phone:251-517-5800
Mailing Address - Fax:251-517-5801
Practice Address - Street 1:770 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-1766
Practice Address - Country:US
Practice Address - Phone:251-517-5800
Practice Address - Fax:251-517-5801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-19
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
AL289502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL28950OtherMEDICAL LICENSE