Provider Demographics
NPI:1144318312
Name:PRATTVILLE MEDICAL CLINIC, PC
Entity type:Organization
Organization Name:PRATTVILLE MEDICAL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLTON
Authorized Official - Middle Name:H
Authorized Official - Last Name:TRINIDAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-358-8106
Mailing Address - Street 1:2257 TAYLOR RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-7790
Mailing Address - Country:US
Mailing Address - Phone:334-270-9914
Mailing Address - Fax:334-270-3195
Practice Address - Street 1:1739 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36066-5525
Practice Address - Country:US
Practice Address - Phone:334-358-8106
Practice Address - Fax:334-358-8107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALJ028Medicare PIN