| Name: | FORT MITCHELL CLINIC P C |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Professional Corporation |
| Status: | Exists |
| Date of registration: | 22 Sep 2011 (13 years ago) (Companies founded in September 2011) |
| Entity Number: | 000-026-020 |
| Register Number: | 000026020 |
| ZIP code: | 36867 (Companies in Russell, 36867) |
| County: | Russell |
| Place of Formation: | Russell County |
| Registered Office Street Address: | 3700 A SOUTH RAILROAD STPRENIX CITY, AL 36867 |
| Authorized Capital: | 100 @ $ 1PV |
Activities
ANY AND ALL LAWFUL ACTIVITIES
| Unique Entity ID | Expiration Date | Physical Address | Mailing Address | |||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| UEAUVLFGYS29 | 2025-02-18 | 2 GILMORE RD, FORT MITCHELL, AL, 36856, 4442, USA | 3700 S RAILROAD ST STE A, PHENIX CITY, AL, 36867, USA | |||||||||||||||||||||||||||||||||||||||||
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| Congressional District | 03 |
| State/Country of Incorporation | AL, USA |
| Activation Date | 2024-02-28 |
| Initial Registration Date | 2023-11-28 |
| Entity Start Date | 2017-06-09 |
| Fiscal Year End Close Date | Dec 31 |
Service Classifications
| NAICS Codes | 621111 |
Points of Contacts
| Electronic Business | |
|---|---|
| Title | PRIMARY POC |
| Name | RAJIV SRIVASTAVA |
| Role | COO |
| Address | 3700 SOUTH RAILROAD ST, STE A, PHENIX CITY, AL, 36867, 2994, USA |
| Government Business | |
|---|---|
| Title | PRIMARY POC |
| Name | RAJIV SRIVASTAVA |
| Role | COO |
| Address | 3700 SOUTH RAILROAD ST, STE A, PHENIX CITY, AL, 36867, 2994, USA |
| Past Performance | Information not Available |
|---|
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1568748242 | 2011-10-26 | 2017-06-09 | 3700 S RAILROAD ST, SUITE A, PHENIX CITY, AL, 368672993, US | 2 GILMORE RD, FT MITCHELL, AL, 368564411, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 334-664-0463 |
| Fax | 3346640466 |
Authorized person
| Name | MR. RAJIV L SRIVASTAVA |
| Role | ADMINISTRATOR |
| Phone | 3346640463 |
Taxonomy
| Taxonomy Code | 207L00000X - Anesthesiology Physician |
| State | AL |
| Is Primary | No |
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| License Number | MD7157 |
| State | AL |
| Is Primary | No |
| Taxonomy Code | 208000000X - Pediatrics Physician |
| License Number | MD26862 |
| State | AL |
| Is Primary | No |
| Taxonomy Code | 261Q00000X - Clinic/Center |
| License Number | MD26862 |
| State | AL |
| Is Primary | No |
| Taxonomy Code | 261QR1300X - Rural Health Clinic/Center |
| License Number | 013962 |
| State | AL |
| Is Primary | Yes |
| Taxonomy Code | 363LF0000X - Family Nurse Practitioner |
| License Number | 1-129486 |
| State | AL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 133816 |
| State | AL |
| Name | Role | Address |
|---|---|---|
| CHANDRA, RITU | Agent | 1415 FALL BRANCH DRIVEPHENIX CITY, AL 36867 |
| Name | Role | Address |
|---|---|---|
| CHANDRA, RITU | Incorporator | 1415 FALL BRANCH DRIVEPHENIX CITY, AL 36867 |
Date of last update: 30 Jul 2024
Sources: Alabama Secretary of State
