Provider Demographics
NPI:1063871184
Name:FMC MEDICAL CLINIC MILLPORT
Entity type:Organization
Organization Name:FMC MEDICAL CLINIC MILLPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHYSICIAN SERVICE
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-759-6165
Mailing Address - Street 1:1820 RICE MINE RD N
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406-3281
Mailing Address - Country:US
Mailing Address - Phone:205-333-4661
Mailing Address - Fax:205-333-4660
Practice Address - Street 1:13530 HIGHWAY 96
Practice Address - Street 2:
Practice Address - City:MILLPORT
Practice Address - State:AL
Practice Address - Zip Code:35576-2522
Practice Address - Country:US
Practice Address - Phone:205-662-3207
Practice Address - Fax:205-333-4660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-17
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL183355Medicaid
AL102G707924Medicare PIN