Provider Demographics
NPI:1932296423
Name:SELMA/DALLAS COUNTY FAMILY PRACTICE, INC
Entity type:Organization
Organization Name:SELMA/DALLAS COUNTY FAMILY PRACTICE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:C
Authorized Official - Last Name:OVERSTREET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-875-7800
Mailing Address - Street 1:7169 AL HIGHWAY 22 N
Mailing Address - Street 2:
Mailing Address - City:VALLEY GRANDE
Mailing Address - State:AL
Mailing Address - Zip Code:36701-9309
Mailing Address - Country:US
Mailing Address - Phone:337-875-7800
Mailing Address - Fax:337-875-0707
Practice Address - Street 1:7169 AL HIGHWAY 22 N
Practice Address - Street 2:
Practice Address - City:VALLEY GRANDE
Practice Address - State:AL
Practice Address - Zip Code:36701-9309
Practice Address - Country:US
Practice Address - Phone:337-875-7800
Practice Address - Fax:337-875-0707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2012-03-30
Deactivation Date:2011-02-01
Deactivation Code:
Reactivation Date:2012-03-23
Provider Licenses
StateLicense IDTaxonomies
AL1429207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051537979Medicare PIN