| Name: | IMC-Family Medical of Jackson, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Professional Limited Liability Company |
| Status: | Dissolved |
| Date of registration: | 22 Jan 1997 (28 years ago) (Companies founded in January 1997) |
| Date of dissolution: | 26 Mar 2019 |
| Entity Number: | 000-185-005 |
| Register Number: | 000185005 |
| Historical Names: |
IMC-Family Medical of Jackson, P.C.
|
| ZIP code: | 36604 (Companies in Mobile, 36604) |
| County: | Mobile |
| Place of Formation: | Mobile County |
| Registered Office Street Address: | 5 MOBILE INFIRMARY CIRCLEMOBILE, AL 36607 |
| Principal Address: | 1700 SPRINGHILL AVENUEMOBILE, AL 36604 |
| Principal Mailing Address: | PO BOX 2226MOBILE, AL 36652 |
Activities
TO RENDER PROFESSIONAL MEDICAL SVCS & SERVICES ANCILLARY THERETO
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1750393682 | 2006-08-12 | 2018-02-23 | 227 HOSPITAL DR, JACKSON, AL, 365452423, US | 227 HOSPITAL DR, JACKSON, AL, 365452423, US | |||||||||||||||||||||||||||||||||||||
|
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| Phone | +1 251-246-4446 |
| Fax | 2512465111 |
Authorized person
| Name | DR. SIDNEY S CROSBY |
| Role | PRESIDENT |
| Phone | 2512464446 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| Is Primary | No |
| Taxonomy Code | 261QR1300X - Rural Health Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 529700760 |
| State | AL |
| Issuer | MEDICAID GROUP # |
| Number | 541003926 |
| State | AL |
| Issuer | MEDICAID |
| Number | 541003926 |
| State | AL |
| Name | Role |
|---|---|
| NIX, D M | Agent |
| Event Date | Event Type | Old Value | New Value |
|---|---|---|---|
| 2017-03-24 | Name Change | IMC-Family Medical of Jackson, P.C. | IMC-Family Medical of Jackson, LLC |
Date of last update: 01 Aug 2024
Sources: Alabama Secretary of State
