Provider Demographics
NPI:1588141063
Name:FMC MEDICAL CLINIC - FAYETTE LLC
Entity type:Organization
Organization Name:FMC MEDICAL CLINIC - FAYETTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORP DIRECTOR PHYSICIAN SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:CLAY
Authorized Official - Last Name:CONVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-759-6165
Mailing Address - Street 1:1653 TEMPLE AVE N STE 1
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:AL
Mailing Address - Zip Code:35555-1314
Mailing Address - Country:US
Mailing Address - Phone:205-932-1421
Mailing Address - Fax:205-932-1428
Practice Address - Street 1:1653 TEMPLE AVE N STE 1
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:AL
Practice Address - Zip Code:35555-1314
Practice Address - Country:US
Practice Address - Phone:205-932-1112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-26
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty