Provider Demographics
NPI:1386719193
Name:EAST ALABAMA FAMILY PRACTICE, P.C.
Entity type:Organization
Organization Name:EAST ALABAMA FAMILY PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:LYLE
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:334-741-0075
Mailing Address - Street 1:2214 GATEWAY DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-1500
Mailing Address - Country:US
Mailing Address - Phone:334-741-0075
Mailing Address - Fax:334-741-4075
Practice Address - Street 1:2214 GATEWAY DR
Practice Address - Street 2:SUITE C
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-1500
Practice Address - Country:US
Practice Address - Phone:334-741-0075
Practice Address - Fax:334-741-4075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO-350207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529602340Medicaid