Provider Demographics
NPI:1730149071
Name:AVALON MEDICAL GROUP
Entity type:Organization
Organization Name:AVALON MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LOREN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-386-0808
Mailing Address - Street 1:PO BOX 2550
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35662-2550
Mailing Address - Country:US
Mailing Address - Phone:256-386-0808
Mailing Address - Fax:256-389-8904
Practice Address - Street 1:2410 AVALON AVE
Practice Address - Street 2:
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661-3283
Practice Address - Country:US
Practice Address - Phone:256-386-0808
Practice Address - Fax:256-389-8904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2025-06-02
Deactivation Date:2024-03-04
Deactivation Code:
Reactivation Date:2024-03-19
Provider Licenses
StateLicense IDTaxonomies
AL3107207Q00000X
ALDO395207Q00000X
AL19137207R00000X
AL5986207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529803460Medicaid
AL529803460Medicaid
ALE354Medicare PIN
AL529803460Medicaid