Provider Demographics
NPI:1427263227
Name:SPECIALTY CLINIC, PC
Entity type:Organization
Organization Name:SPECIALTY CLINIC, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:T
Authorized Official - Last Name:BOYINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:334-427-2273
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:ANDALUSIA
Mailing Address - State:AL
Mailing Address - Zip Code:36420-1205
Mailing Address - Country:US
Mailing Address - Phone:334-472-9427
Mailing Address - Fax:334-222-2183
Practice Address - Street 1:508 E THREE NOTCH ST
Practice Address - Street 2:
Practice Address - City:ANDALUSIA
Practice Address - State:AL
Practice Address - Zip Code:36420-3128
Practice Address - Country:US
Practice Address - Phone:334-472-9427
Practice Address - Fax:334-222-2183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO439207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529901030Medicaid
AL051078763OtherALABAMA BLUE CROSS
ALG08213Medicare UPIN
AL529901030Medicaid