Provider Demographics
NPI:1063804052
Name:FULTONDALE URGENT CARE LLC
Entity type:Organization
Organization Name:FULTONDALE URGENT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-841-2844
Mailing Address - Street 1:339 WALKER CHAPEL PLZ
Mailing Address - Street 2:SUITE 115
Mailing Address - City:FULTONDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35068-3401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:339 WALKER CHAPEL PLZ
Practice Address - Street 2:SUITE 115
Practice Address - City:FULTONDALE
Practice Address - State:AL
Practice Address - Zip Code:35068-3401
Practice Address - Country:US
Practice Address - Phone:205-841-2844
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-27
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALDQ4012OtherRRMC
AL0CXJ1OtherBCBS
615236400OtherDOL
AL169110Medicaid
AL1659697696OtherTRICARE SOUTH
615236400OtherDOL