Provider Demographics
NPI:1891930491
Name:SHOALS MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:SHOALS MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-320-5405
Mailing Address - Street 1:1120 S JACKSON HWY
Mailing Address - Street 2:SUITE 301-B
Mailing Address - City:SHEFFIELD
Mailing Address - State:AL
Mailing Address - Zip Code:35660-5777
Mailing Address - Country:US
Mailing Address - Phone:256-320-5405
Mailing Address - Fax:256-320-5407
Practice Address - Street 1:1120 S JACKSON HWY
Practice Address - Street 2:SUITE 301-B
Practice Address - City:SHEFFIELD
Practice Address - State:AL
Practice Address - Zip Code:35660-5777
Practice Address - Country:US
Practice Address - Phone:256-320-5405
Practice Address - Fax:256-320-5407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22371208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL6210700001Medicare NSC