Provider Demographics
NPI:1104901438
Name:SOUTHEAST ALABAMA MATERNITY CARE PROGRAM
Entity type:Organization
Organization Name:SOUTHEAST ALABAMA MATERNITY CARE PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-712-3784
Mailing Address - Street 1:PO BOX 6987
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-6987
Mailing Address - Country:US
Mailing Address - Phone:334-712-3784
Mailing Address - Fax:334-712-3249
Practice Address - Street 1:545 W MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1653
Practice Address - Country:US
Practice Address - Phone:334-712-3784
Practice Address - Fax:334-712-3249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization