| Name: | Functional Medicine of Alabama, P.C. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Professional Corporation |
| Status: | Exists |
| Date of registration: | 08 Aug 2018 (6 years ago) |
| Entity Number: | 000-526-248 |
| Register Number: | 000526248 |
| County: | Shelby |
| Place of Formation: | Jefferson County |
| Principal Address: | 2545 INVERNESS POINT DRIVEBIRMINGHAM, AL 35242 |
| Principal Address ZIP Code: | 35242 |
| Authorized Capital: | 100 |
Activities
HEALTH CARE-MEDICAL DOCTOR
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1356567721 | 2007-04-17 | 2019-02-15 | 2228 CAHABA VALLEY DR, BIRMINGHAM, AL, 35242, US | 2228 CAHABA VALLEY DR, BIRMINGHAM, AL, 35242, US | |||||||||||||||||||||||||||||||
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| Phone | +1 205-593-4200 |
| Fax | 2056721009 |
Authorized person
| Name | MARIAN LEIGH ST. PETERY |
| Role | PHYSICIAN/OWNER |
| Phone | 2055934200 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| License Number | DO-797 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BCBS |
| Number | 515-27516 |
| State | AL |
| Issuer | MEDICARE GROUP # |
| Number | K374 |
| State | AL |
| Name | Role | Address |
|---|---|---|
| ST PETERY, MARIAN LEIGH | Agent | 2545 INVERNESS POINT DRIVEBIRMINGHAM, AL 35242 |
| Name | Role | Address |
|---|---|---|
| ST PETERY, MARIAN LEIGH | Director | 2545 INVERNESS POINT DRIVEBIRMINGHAM, AL 35242 |
| Name | Role | Address |
|---|---|---|
| LEGALZOOM.COM INC | Incorporator | 101 N BRAND BLVD 10TH FLOORGLENDALE, CA 91203 |
Date of last update: 14 Aug 2024
Sources: Alabama Secretary of State
