Provider Demographics
NPI:1811288038
Name:SOUTH ALABAMA MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:SOUTH ALABAMA MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGOT
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-445-7618
Mailing Address - Street 1:10075 GRAND BAY WILMER RD S
Mailing Address - Street 2:
Mailing Address - City:GRAND BAY
Mailing Address - State:AL
Mailing Address - Zip Code:36541-5003
Mailing Address - Country:US
Mailing Address - Phone:251-865-1852
Mailing Address - Fax:251-865-1854
Practice Address - Street 1:10075 GRAND BAY WILMER RD S
Practice Address - Street 2:
Practice Address - City:GRAND BAY
Practice Address - State:AL
Practice Address - Zip Code:36541-5003
Practice Address - Country:US
Practice Address - Phone:251-865-1852
Practice Address - Fax:251-865-1854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2024-08-29
Deactivation Date:2024-07-23
Deactivation Code:
Reactivation Date:2024-07-31
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 207Q00000X, 208000000X, 261QM0850X, 261QM0855X, 363LP0808X
AL1-072232208D00000X
AL261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL140171OtherRURAL HEALTH MEDICAID
AL129323Medicaid