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Dermatology Associates of Montgomery, LLC

Details

Name: Dermatology Associates of Montgomery, LLC
Jurisdiction: Alabama
Legal type: Domestic Limited Liability Company
Status: Dissolved
Date of registration: 02 Dec 2011 (13 years ago)
Date of dissolution: 02 May 2023
Entity Number: 000-032-741
Register Number: 000032741
County: Montgomery
Place of Formation: Montgomery County
Registered Office Mailing Address: PO BOX 241627MONTGOMERY, AL 36124-1627
Registered Office Street Address: 286 MITYLENE PARK DRIVEMONTGOMERY, AL 36117
Registered Office Street Address ZIP Code: 36117

Activities PRACTICE OF MEDICINE

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1891064937 2011-12-19 2012-12-19 PO BOX 241627, MONTGOMERY, AL, 361241627, US 286 MITYLENE PARK DR, MONTGOMERY, AL, 361173548, US

Contacts
Phone +1 334-396-1555
Fax 3343969833

Authorized person
Name MS. CAROLYN STONE BARRETT
Role OFFICE MANAGER
Phone 3343968774

Taxonomy
Taxonomy Code 174400000X - Specialist
License Number 10825
State AL
Is Primary Yes

Other Provider Identifiers
Issuer MEDICAID
Number 528501290
State AL
Issuer RAILROAD MEDICARE
Number CM4358
State AL

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
DERMATOLOGY ASSOCIATES OF MONTGOMERY 401(K) PLAN 2021 453970660 2022-09-01 DERMATOLOGY ASSOCIATES OF MONTGOMERY, LLC 10
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1985-01-01
Business code 621111
Sponsor’s telephone number 3343961555
Plan sponsor’s address 286 MITYLENE PARK DRIVE, PO BOX 241627, MONTGOMERY, AL, 361241627
DERMATOLOGY ASSOCIATES OF MONTGOMERY 401(K) PLAN 2021 453970660 2022-10-03 DERMATOLOGY ASSOCIATES OF MONTGOMERY, LLC 1
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1985-01-01
Business code 621111
Sponsor’s telephone number 3343961555
Plan sponsor’s address 286 MITYLENE PARK DRIVE, PO BOX 241627, MONTGOMERY, AL, 361241627

Signature of
Role Plan administrator
Date 2022-10-01
Name of individual signing CHRISTINE RIMER
DERMATOLOGY ASSOCIATES OF MONTGOMERY 401(K) PLAN 2020 453970660 2021-10-13 DERMATOLOGY ASSOCIATES OF MONTGOMERY, LLC 10
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1985-01-01
Business code 621111
Sponsor’s telephone number 3343961555
Plan sponsor’s address 286 MITYLENE PARK DRIVE, PO BOX 241627, MONTGOMERY, AL, 361241627

Plan administrator’s name and address
Administrator’s EIN 474474775
Plan administrator’s name GUIDELINE, INC.
Plan administrator’s address 1645 E 6TH STREET, SUITE 200, AUSTIN, TX, 78702
Administrator’s telephone number 8882283491

Signature of
Role Plan administrator
Date 2021-10-13
Name of individual signing CAROL HO
DERMATOLOGY ASSOCIATES OF MONTGOMERY, LLC 401(K) PROFIT SHARING PLAN 2019 453970660 2020-05-12 DERMATOLOGY ASSOCIATES OF MONTGOMERY, LLC 14
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1985-01-01
Business code 621111
Sponsor’s telephone number 3343961555
Plan sponsor’s address 286 MITYLENE PARK DRIVE, MONTGOMERY, AL, 36124

Signature of
Role Plan administrator
Date 2020-05-12
Name of individual signing JAMES MADDOX
DERMATOLOGY ASSOCIATES OF MONTGOMERY, LLC 401(K) PROFIT SHARING PLAN 2018 453970660 2019-08-15 DERMATOLOGY ASSOCIATES OF MONTGOMERY, LLC 17
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1985-01-01
Business code 621111
Sponsor’s telephone number 3343961555
Plan sponsor’s address 286 MITYLENE PARK DRIVE, MONTGOMERY, AL, 36124

Signature of
Role Plan administrator
Date 2019-08-15
Name of individual signing JAMES MADDOX
DERMATOLOGY ASSOCIATES OF MONTGOMERY, LLC 401(K) PROFIT SHARING PLAN 2017 453970660 2018-07-19 DERMATOLOGY ASSOCIATES OF MONTGOMERY, LLC 14
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1985-01-01
Business code 621111
Sponsor’s telephone number 3343961555
Plan sponsor’s address 286 MITYLENE PARK DRIVE, MONTGOMERY, AL, 36124

Signature of
Role Plan administrator
Date 2018-07-19
Name of individual signing JAMES MADDOX
DERMATOLOGY ASSOCIATES OF MONTGOMERY, LLC 401(K) PROFIT SHARING PLAN 2016 453970660 2017-10-09 DERMATOLOGY ASSOCIATES OF MONTGOMERY, LLC 15
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1985-01-01
Business code 621111
Sponsor’s telephone number 3343961555
Plan sponsor’s address 286 MITYLENE PARK DRIVE, MONTGOMERY, AL, 36124

Signature of
Role Plan administrator
Date 2017-10-09
Name of individual signing JAMES MADDOX
DERMATOLOGY ASSOCIATES OF MONTGOMERY, LLC 401(K) PROFIT SHARING PLAN 2015 453970660 2016-08-17 DERMATOLOGY ASSOCIATES OF MONTGOMERY, LLC 15
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1985-01-01
Business code 621111
Sponsor’s telephone number 3343961555
Plan sponsor’s address 286 MITYLENE PARK DRIVE, MONTGOMERY, AL, 36124

Signature of
Role Plan administrator
Date 2016-08-17
Name of individual signing JAMES MADDOX

Agent

Name Role
MADDOX, J S Agent

Organizer

Name Role Address
MADDOX, J STEPHEN Organizer 286 MITYLENE PARK DRIVEMONTGOMERY, AL 36117
DALTON, MICHAEL P Organizer 150 SOUTH PERRY STREETMONTGOMERY, AL 36104-3960
BARNETT, ELISE P Organizer No data

Related by officers

MADDOX, J S

JSM Realty, LLC J. S. Maddox, Inc.

DALTON, MICHAEL P

Prattville (AL)- Cobbs Ford Road Syndicated Holdings, LLC Heritage Medical Billing Services, LLC Moss Hammock, LLC Hanwool Construction, Inc. HHM Properties, LLC Coleman Taylor, LLC Pike Road Rehab, LLC POWN Music, LLC Intellimesh Systems, Inc. The Way Home, Inc.

Related by address

PO BOX 241627MONTGOMERY, AL 36124-1627

JSM Realty, LLC

286 MITYLENE PARK DRIVEMONTGOMERY, AL 36117

JSM Realty, LLC

Date of last update: 30 Jul 2024

Sources: Alabama Secretary of State

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