Organization
FORT MITCHELL CLINIC PC
Active
Other names
Preferred Medical Group
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RAJIV L SRIVASTAVA MBA (ADMINISTRATOR)
(334) 664-0463
Entity
Organization
Contact information
Practice address
2 GILMORE RD, FT MITCHELL, AL 36856-4411
(334) 664-0463
(334) 664-0466
Mailing address
3700 S RAILROAD ST, SUITE A, PHENIX CITY, AL 36867-2993
(334) 664-0463
(334) 664-0466
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
—
AL
207Q00000X
Family Medicine Physician
MD7157
AL
208000000X
Pediatrics Physician
MD26862
AL
261Q00000X
Clinic/Center
MD26862
AL
261QR1300X
Rural Health Clinic/Center
Primary
013962
AL
363LF0000X
Family Nurse Practitioner
1-129486
AL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
133816
—
AL
Enumeration date
10/26/2011
Last updated
06/09/2017
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