Provider Demographics
NPI:1063575363
Name:CYRIAC MADATHIKUNNEL, MD, LLC
Entity type:Organization
Organization Name:CYRIAC MADATHIKUNNEL, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NIRMALA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADATHIKUNNEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-872-3339
Mailing Address - Street 1:1013 MEDICAL CENTER PKWY
Mailing Address - Street 2:FRIST HOWELL BUILDING # 3
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701-6742
Mailing Address - Country:US
Mailing Address - Phone:334-872-3339
Mailing Address - Fax:334-872-6200
Practice Address - Street 1:1013 MEDICAL CENTER PKWY
Practice Address - Street 2:FRIST HOWELL BUILDING # 3
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-6742
Practice Address - Country:US
Practice Address - Phone:334-872-3339
Practice Address - Fax:334-872-6200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00019370207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529914120Medicaid
AL51514539OtherBCBS OF ALABAMA
AL529914120Medicaid
AL051553351Medicare ID - Type Unspecified