| Name: | Obstetrics and Gynecology of Dothan, Inc. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Corporation |
| Status: | Exists |
| Date of registration: | 30 May 2001 (23 years ago) |
| Entity Number: | 000-216-799 |
| Register Number: | 000216799 |
| Place of Formation: | Houston County |
| Registered Office Street Address: | 112 WEST TROY STDOTHAN, AL 36302-0668 |
| Registered Office Mailing Address: | P O BOX 668DOTHAN, AL 36302-0668 |
| Authorized Capital: | $1,000 |
| Paid Share Capital: | $100 |
Activities
OBSTETRICS/GYNECOLOGY
| Unique Entity ID | Expiration Date | Physical Address | Mailing Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| JLZMBTMKZH15 | 2024-07-18 | 1458 WHATLEY DR, DOTHAN, AL, 36303, 1994, USA | 1458 WHATLEY DR, DOTHAN, AL, 36303, 1994, USA | |||||||||||||||||||||||||||||||||||||||||||||||||||||
|
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| Congressional District | 02 |
| State/Country of Incorporation | AL, USA |
| Activation Date | 2023-07-21 |
| Initial Registration Date | 2007-06-01 |
| Entity Start Date | 2001-05-01 |
| Fiscal Year End Close Date | Dec 31 |
Service Classifications
| NAICS Codes | 621111 |
Points of Contacts
| Electronic Business | |
|---|---|
| Title | PRIMARY POC |
| Name | CASSONDRA CHADWICK |
| Address | 1458 WHATLEY DRIVE, DOTHAN, AL, 36303, 1994, USA |
| Title | ALTERNATE POC |
| Name | CASSONDRA CHADWICK |
| Address | 104 MEDICAL DRIVE, DOTHAN, AL, 36303, 6902, USA |
| Government Business | |
|---|---|
| Title | PRIMARY POC |
| Name | DAVID HALCOMB |
| Address | 1458 WHATLEY DRIVE, DOTHAN, AL, 36303, 1994, USA |
| Title | ALTERNATE POC |
| Name | CASSONDRA CHADWICK |
| Address | 104 MEDICAL DRIVE, DOTHAN, AL, 36303, 6902, USA |
| Past Performance | Information not Available |
|---|
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1114021409 | 2006-09-08 | 2015-12-04 | 104 MEDICAL DR, DOTHAN, AL, 36303, US | 104 MEDICAL DR, DOTHAN, AL, 36303, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 334-671-9445 |
| Fax | 3348360059 |
Authorized person
| Name | DANA GAYLORD |
| Role | ADMINISTRATIVE ASSISTANT |
| Phone | 3346719445 |
Taxonomy
| Taxonomy Code | 207V00000X - Obstetrics & Gynecology Physician |
| License Number | 23245 |
| State | AL |
| Is Primary | No |
| Taxonomy Code | 207V00000X - Obstetrics & Gynecology Physician |
| License Number | 26014 |
| State | AL |
| Is Primary | Yes |
| Taxonomy Code | 207V00000X - Obstetrics & Gynecology Physician |
| License Number | DO1161 |
| State | AL |
| Is Primary | No |
| Taxonomy Code | 207V00000X - Obstetrics & Gynecology Physician |
| License Number | 31759 |
| State | AL |
| Is Primary | No |
| Taxonomy Code | 207V00000X - Obstetrics & Gynecology Physician |
| License Number | 31756 |
| State | AL |
| Is Primary | No |
| Taxonomy Code | 207V00000X - Obstetrics & Gynecology Physician |
| License Number | 32437 |
| State | AL |
| Is Primary | No |
| Taxonomy Code | 207V00000X - Obstetrics & Gynecology Physician |
| State | AL |
| Is Primary | No |
| Taxonomy Code | 363A00000X - Physician Assistant |
| License Number | PA-204 |
| State | AL |
| Is Primary | No |
| Taxonomy Code | 363LX0001X - Obstetrics & Gynecology Nurse Practitioner |
| License Number | 1006758 |
| State | AL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | CLIA WAVIER |
| Number | 01D2068157 |
| Issuer | CLIA WAIVED |
| Number | 01D0989955 |
| Issuer | MEDICARE GROUP NUMBER |
| Number | 1826 |
| Issuer | MEDICAL PROTECTIVE |
| Number | C47766 |
| Issuer | MEDICAID GROUP |
| Number | 529928670 |
| Issuer | CLIA WAIVED |
| Number | 01D2043043 |
| State | AL |
| Issuer | MEDICAID |
| Number | 051502953 |
| State | AL |
| Issuer | CLIA WAIVED |
| Number | 01D2052896 |
| State | AL |
| Issuer | CLIA WAIVED |
| Number | 01D2074304 |
| Issuer | MEDICAID |
| Number | 051520983 |
| State | AL |
| Name | Role | Address |
|---|---|---|
| MALONE, W DAVIS III | Agent | 20 HAMPTON WAYDOTHAN, AL 36305 |
| Name | Role | Address |
|---|---|---|
| VOSS, ASHA | Incorporator | 100 GOOSEBERRY LANEDOTHAN, AL 36305 |
Date of last update: 01 Aug 2024
Sources: Alabama Secretary of State
