Provider Demographics
NPI:1104456920
Name:SOUTHERN DIVINE FAMILY MEDICAL CENTER LLC
Entity type:Organization
Organization Name:SOUTHERN DIVINE FAMILY MEDICAL CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ENRICO
Authorized Official - Middle Name:D
Authorized Official - Last Name:GASPAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-840-8181
Mailing Address - Street 1:PO BOX 35
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:AL
Mailing Address - Zip Code:35952-0035
Mailing Address - Country:US
Mailing Address - Phone:205-589-1092
Mailing Address - Fax:205-589-1096
Practice Address - Street 1:7130 6TH AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:AL
Practice Address - Zip Code:35952-9052
Practice Address - Country:US
Practice Address - Phone:205-589-1092
Practice Address - Fax:205-589-1096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-21
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty