Provider Demographics
NPI:1588752844
Name:ELBERTA CLINIC, PC
Entity type:Organization
Organization Name:ELBERTA CLINIC, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KURTTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-986-7301
Mailing Address - Street 1:24980 STATE ST
Mailing Address - Street 2:PO DRAWER 519
Mailing Address - City:ELBERTA
Mailing Address - State:AL
Mailing Address - Zip Code:36530-2573
Mailing Address - Country:US
Mailing Address - Phone:251-986-7301
Mailing Address - Fax:251-986-5927
Practice Address - Street 1:24980 STATE ST
Practice Address - Street 2:PO DRAWER 519
Practice Address - City:ELBERTA
Practice Address - State:AL
Practice Address - Zip Code:36530-2573
Practice Address - Country:US
Practice Address - Phone:251-986-7301
Practice Address - Fax:251-986-5927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529500390Medicaid
ALBCBSOtherBLUE CROSS BLUE SHIELD AL
ALCN3899OtherRAILROAD MEDICARE
ALBCBSOtherBLUE CROSS BLUE SHIELD AL