Provider Demographics
NPI:1063771053
Name:ROYSE FAMILY MEDICINE
Entity type:Organization
Organization Name:ROYSE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROYSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-233-5145
Mailing Address - Street 1:727 W MARKET ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35611-2456
Mailing Address - Country:US
Mailing Address - Phone:256-233-5145
Mailing Address - Fax:256-230-2615
Practice Address - Street 1:727 W MARKET ST
Practice Address - Street 2:SUITE D
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35611-2456
Practice Address - Country:US
Practice Address - Phone:256-233-5145
Practice Address - Fax:256-230-2615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-10
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00025382207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL138775Medicaid