| Name: | Gadsden Regional Physician Group Practice, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Foreign Limited Liability Company |
| Status: | Exists |
| Date of registration: | 19 Aug 2008 (16 years ago) (Companies founded in August 2008) |
| Entity Number: | 000-616-494 |
| Register Number: | 000616494 |
| ZIP code: | 36104 (Companies in Montgomery, 36104) |
| County: | Montgomery |
| Place of Formation: | Delaware |
| Principal Address: | 4000 MERIDIAN BLVDFRANKLIN, TN 37067 |
| Principal Mailing Address: | ONE CVS DRIVEWOONSOCKET, RI 02895 |
| Registered Office Street Address: | 641 SOUTH LAWRENCE STREETMONTGOMERY, AL 36104 |
Activities
HEALTH CARE SERVICES
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1558506550 | 2008-12-05 | 2023-04-25 | PO BOX 689022, FRANKLIN, TN, 370689022, US | 100 MEDICAL CENTER DR, SUITE 308, GADSDEN, AL, 359031134, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 615-465-3334 |
| Fax | 6156286877 |
| Phone | +1 256-494-4646 |
| Fax | 2564944649 |
Authorized person
| Name | JENNIFER L JACKSON |
| Role | SR DIR PROV ENROLLMENT & ONBOARDING |
| Phone | 6154653334 |
Taxonomy
| Taxonomy Code | 207L00000X - Anesthesiology Physician |
| Is Primary | No |
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| Is Primary | Yes |
| Taxonomy Code | 207R00000X - Internal Medicine Physician |
| Is Primary | No |
| Taxonomy Code | 207RP1001X - Pulmonary Disease Physician |
| Is Primary | No |
| Taxonomy Code | 208000000X - Pediatrics Physician |
| Is Primary | No |
| Taxonomy Code | 2084P0800X - Psychiatry Physician |
| Is Primary | No |
| Taxonomy Code | 208M00000X - Hospitalist Physician |
| Is Primary | No |
| Taxonomy Code | 367500000X - Certified Registered Nurse Anesthetist |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 1558506550/109105 |
| State | AL |
| Name | Role | Address |
|---|---|---|
| CORPORATION SERVICE COMPANY INC | Agent | 251 LITTLE FALLS DRIVEWILMINGTON, DE 19808 |
Date of last update: 15 Aug 2024
Sources: Alabama Secretary of State
