Provider Demographics
NPI:1144301128
Name:STAFF OF LIFE MED CORP PC
Entity type:Organization
Organization Name:STAFF OF LIFE MED CORP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFF MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:S
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-770-7197
Mailing Address - Street 1:1011 LEIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36207-5701
Mailing Address - Country:US
Mailing Address - Phone:256-770-7197
Mailing Address - Fax:256-405-4439
Practice Address - Street 1:1011 LEIGHTON AVE
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-5701
Practice Address - Country:US
Practice Address - Phone:256-770-7197
Practice Address - Fax:256-405-4439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19946173000000X
173000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529919080Medicaid
AL158627Medicaid