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Jefferson Clinic, P.C.

Details

Name: Jefferson Clinic, P.C.
Jurisdiction: Alabama
Legal type: Domestic Professional Corporation
Status: Exists
Date of registration: 30 Dec 1974 (50 years ago) (Companies founded in December 1974)
Entity Number: 000-036-502
Register Number: 000036502
ZIP code: 35233 (Companies in Jefferson, 35233)
County: Jefferson
Place of Formation: Jefferson County
Principal Address: BIRMINGHAM, AL
Registered Office Street Address: 1526 5TH AVENUE SOUTHBIRMINGHAM, AL 35233
Authorized Capital: $50,000
Paid Share Capital: $1,000

National Provider Identifier

NPI Enumeration Date Last Update Date Mailing Address Practice Location Address
1124086509 2006-05-03 2013-01-23 1526 5TH AVE S, BIRMINGHAM, AL, 352331615, US 1526 5TH AVE S, BIRMINGHAM, AL, 352331615, US

Contacts
Phone +1 205-279-2860
Fax 2052517698

Authorized person
Name MS. DANIELLE RENEE BROWN
Role BUSINESS ADMINISTRATOR
Phone 2052792860

Taxonomy
Taxonomy Code 207Q00000X - Family Medicine Physician
State AL
Is Primary No
Taxonomy Code 207R00000X - Internal Medicine Physician
State AL
Is Primary Yes
Taxonomy Code 207RC0200X - Critical Care Medicine (Internal Medicine) Physician
State AL
Is Primary No
Taxonomy Code 207RH0003X - Hematology & Oncology Physician
State AL
Is Primary No
Taxonomy Code 207RP1001X - Pulmonary Disease Physician
State AL
Is Primary No
Taxonomy Code 207V00000X - Obstetrics & Gynecology Physician
State AL
Is Primary No
Taxonomy Code 207W00000X - Ophthalmology Physician
State AL
Is Primary No
Taxonomy Code 207X00000X - Orthopaedic Surgery Physician
State AL
Is Primary No
Taxonomy Code 207Y00000X - Otolaryngology Physician
State AL
Is Primary No
Taxonomy Code 207ZP0102X - Anatomic Pathology & Clinical Pathology Physician
State AL
Is Primary No
Taxonomy Code 2084P0800X - Psychiatry Physician
State AL
Is Primary No
Taxonomy Code 2085R0202X - Diagnostic Radiology Physician
State AL
Is Primary No
Taxonomy Code 208600000X - Surgery Physician
State AL
Is Primary No
Taxonomy Code 208800000X - Urology Physician
State AL
Is Primary No
Taxonomy Code 208VP0000X - Pain Medicine Physician
State AL
Is Primary No

Other Provider Identifiers
Issuer MEDICAID
Number 000060093
State AL

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
JEFFERSON CLINIC, P.C. PROFIT SHARING PLAN 2013 630635873 2014-07-29 JEFFERSON CLINIC P. C. 7
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1974-08-30
Business code 621111
Sponsor’s telephone number 2058711880
Plan sponsor’s mailing address 2204 LAKESHORE DRIVE SUITE 300, BIRMINGHAM, AL, 35209
Plan sponsor’s address 2204 LAKESHORE DRIVE SUITE 300, BIRMINGHAM, AL, 35209

Plan administrator’s name and address
Administrator’s EIN 630352192
Plan administrator’s name JEFFERSON CLINIC, P.C.
Plan administrator’s address 2204 LAKESHORE DRIVE. SUITE 300, BIRMINGHAM, AL, 35209

Number of participants as of the end of the plan year
Active participants 0
Retired or separated participants receiving benefits 0
Other retired or separated participants entitled to future benefits 0
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits 0
Number of participants with account balances as of the end of the plan year 0
JEFFERSON CLINIC, P.C. PROFIT SHARING PLAN 2013 630635873 2014-04-15 JEFFERSON CLINIC P. C. 77
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1974-08-30
Business code 621111
Sponsor’s telephone number 2058711880
Plan sponsor’s mailing address 2204 LAKESHORE DRIVE SUITE 300, BIRMINGHAM, AL, 35209
Plan sponsor’s address 2204 LAKESHORE DRIVE SUITE 300, BIRMINGHAM, AL, 35209

Plan administrator’s name and address
Administrator’s EIN 630352192
Plan administrator’s name JEFFERSON CLINIC, P.C.
Plan administrator’s address 2204 LAKESHORE DRIVE. SUITE 300, BIRMINGHAM, AL, 35209

Number of participants as of the end of the plan year
Other retired or separated participants entitled to future benefits 7
Number of participants with account balances as of the end of the plan year 7
JEFFERSON CLINIC, P. C. PROFIT SHARING PLAN 2012 630635873 2014-08-12 JEFFERSON CLINIC, P. C. 98
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1974-08-30
Business code 621111
Sponsor’s telephone number 2058717880
Plan sponsor’s mailing address 2204 LAKESHORE DRIVE SUITE 300, BIRMINGHAM, AL, 35209
Plan sponsor’s address 2204 LAKESHORE DRIVE STE 3000, BIRMINGHAM, AL, 35209

Number of participants as of the end of the plan year
Active participants 71
Retired or separated participants receiving benefits 0
Other retired or separated participants entitled to future benefits 22
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits 1

Signature of
Role Plan administrator
Date 2014-08-12
Name of individual signing WILLIAM O. WHITT
Valid signature Filed with authorized/valid electronic signature
JEFFERSON CLINIC, P.C. PROFIT SHARING PLAN 2011 630635873 2012-04-10 JEFFERSON CLINIC, P.C. 94
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1974-08-30
Business code 621111
Sponsor’s telephone number 2055216200
Plan sponsor’s mailing address 1526 5TH AVENUE SOUTH, BIRMINGHAM, AL, 35233
Plan sponsor’s address 1526 5TH AVENUE SOUTH, BIRMINGHAM, AL, 35233

Plan administrator’s name and address
Administrator’s EIN 630635873
Plan administrator’s name JEFFERSON CLINIC, P.C.
Plan administrator’s address 1526 5TH AVENUE SOUTH, BIRMINGHAM, AL, 35233
Administrator’s telephone number 2055216200

Number of participants as of the end of the plan year
Active participants 77
Retired or separated participants receiving benefits 2
Other retired or separated participants entitled to future benefits 19
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits 0
Number of participants with account balances as of the end of the plan year 82
Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 1

Signature of
Role Plan administrator
Date 2012-04-10
Name of individual signing DANIELLE BROWN
Valid signature Filed with authorized/valid electronic signature
JEFFERSON CLINIC, P.C. PROFIT SHARING PLAN 2010 630635873 2011-05-02 JEFFERSON CLINIC, P.C. 94
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1974-08-30
Business code 621111
Sponsor’s telephone number 2055216200
Plan sponsor’s mailing address 1526 5TH AVENUE SOUTH, BIRMINGHAM, AL, 35233
Plan sponsor’s address 1526 5TH AVENUE SOUTH, BIRMINGHAM, AL, 35233

Plan administrator’s name and address
Administrator’s EIN 630635873
Plan administrator’s name JEFFERSON CLINIC, P.C.
Plan administrator’s address 1526 5TH AVENUE SOUTH, BIRMINGHAM, AL, 35233
Administrator’s telephone number 2055216200

Number of participants as of the end of the plan year
Active participants 68
Retired or separated participants receiving benefits 3
Other retired or separated participants entitled to future benefits 23
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits 0
Number of participants with account balances as of the end of the plan year 92
Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 4

Signature of
Role Plan administrator
Date 2011-05-02
Name of individual signing DANIELLE BROWN
Valid signature Filed with authorized/valid electronic signature
JEFFERSON CLINIC, P.C. PROFIT SHARING PLAN 2009 630635873 2010-04-22 JEFFERSON CLINIC, P.C. 91
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1974-08-30
Business code 621111
Sponsor’s telephone number 2055216200
Plan sponsor’s mailing address 1526 5TH AVENUE SOUTH, BIRMINGHAM, AL, 35233
Plan sponsor’s address 1526 5TH AVENUE SOUTH, BIRMINGHAM, AL, 35233

Plan administrator’s name and address
Administrator’s EIN 630635873
Plan administrator’s name JEFFERSON CLINIC, P.C.
Plan administrator’s address 1526 5TH AVENUE SOUTH, BIRMINGHAM, AL, 35233
Administrator’s telephone number 2055216200

Number of participants as of the end of the plan year
Active participants 71
Retired or separated participants receiving benefits 3
Other retired or separated participants entitled to future benefits 20
Deceased participants whose beneficiaries are receiving or are entitled to receive benefits 0
Number of participants with account balances as of the end of the plan year 94
Number of participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2

Signature of
Role Plan administrator
Date 2010-04-22
Name of individual signing DANIELLE BROWN
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role
BROWN, DANIELLE Agent

Incorporator

Name Role
ASHFORD, ROWELL S Incorporator
BREAUX, CHARLES W Incorporator
CHATTERJEE, C R Incorporator
CHOI, HANSEEK Incorporator
KHARE, SANTOSH K Incorporator
MERCER, CHARLES W Incorporator
PRESTON, RHEA S Incorporator
SAMUELS, JOSEPH W Incorporator
SHERRILL, EOBERT G JR Incorporator
SUTTON, FRANK D Incorporator

Events

Event Date Event Type Old Value New Value
1975-01-02 Name Merged No data Jefferson Clinic, P.A.

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CHATTERJEE, C R

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KHARE, SANTOSH K

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MERCER, CHARLES W

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PRESTON, RHEA S

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SAMUELS, JOSEPH W

Jefferson Clinic, P.A.

SUTTON, FRANK D

Partners In Progress X, L.L.P. Partners In Progress VII, L.L.P.

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Date of last update: 30 Jul 2024

Sources: Alabama Secretary of State

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