Provider Demographics
NPI:1588688246
Name:ASSOCIATED MEDICAL GROUP PC
Entity type:Organization
Organization Name:ASSOCIATED MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LELAND
Authorized Official - Middle Name:N
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:205-871-0050
Mailing Address - Street 1:PO BOX 130070
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35213-0070
Mailing Address - Country:US
Mailing Address - Phone:205-871-0050
Mailing Address - Fax:205-871-0050
Practice Address - Street 1:636 2ND ST NE
Practice Address - Street 2:SUITE B
Practice Address - City:ALABASTER
Practice Address - State:AL
Practice Address - Zip Code:35007
Practice Address - Country:US
Practice Address - Phone:205-664-4377
Practice Address - Fax:205-664-3694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2007-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL18247208M00000X, 207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51004116OtherBLUE CROSS BLUE SHIELD
ALF87204Medicare UPIN