Provider Demographics
NPI:1649696196
Name:PRATTVILLE CHRISTIAN FAMILY MEDICINE
Entity type:Organization
Organization Name:PRATTVILLE CHRISTIAN FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCINTYRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-279-8180
Mailing Address - Street 1:128 MITYLENE PARK LN
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-3758
Mailing Address - Country:US
Mailing Address - Phone:334-279-8180
Mailing Address - Fax:334-279-8214
Practice Address - Street 1:478 MCQUEEN SMITH RD S
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36066-5631
Practice Address - Country:US
Practice Address - Phone:334-356-9200
Practice Address - Fax:334-356-1064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-07
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00025985207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty