| Name: | J. Andre Taylor, M.D., LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Dissolved |
| Date of registration: | 30 Dec 1999 (25 years ago) |
| Date of dissolution: | 26 Dec 2012 |
| Entity Number: | 000-667-806 |
| Register Number: | 000667806 |
| County: | Colbert |
| Place of Formation: | Colbert County |
| Principal Address: | MUSCLE SHOALS, AL |
| Registered Office Street Address: | 102 PHYSICIANS DR STE 1MUSCLE SHOALS, AL 35661 |
| Registered Office Street Address ZIP Code: | 35661 |
Activities
PRACTICE OF MEDICINE
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1245306380 | 2006-11-28 | 2009-10-20 | 1100 S MONTGOMERY AVE, SHEFFIELD, AL, 356606330, US | 1100 S MONTGOMERY AVE, SHEFFIELD, AL, 356606330, US | |||||||||||||||||||||||||||||||||||||
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| Phone | +1 256-381-8200 |
| Fax | 2563836753 |
Authorized person
| Name | JACK ANDRE TAYLOR |
| Role | PRESIDENT |
| Phone | 2563818200 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| License Number | 12828 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | RAILRROAD MEDICARE |
| Number | DA3810 |
| State | AL |
| Issuer | MEDICAID |
| Number | 051554360TAY |
| State | AL |
| Issuer | BCBS OF ALABAMA |
| Number | 051554360TAY |
| State | AL |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| J. ANDRE TAYLOR, M.D. PROFIT SHARING PLAN & TRUST | 2012 | 630991793 | 2013-06-19 | J. ANDRE TAYLOR, M.D. | 7 | |||||||||||||||||||||||||||||
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| Administrator’s EIN | 630991793 |
| Plan administrator’s name | J. ANDRE TAYLOR, M.D. |
| Plan administrator’s address | 1100 SOUTH MONTGOMERY AVENUE, SHEFFIELD, AL, 35660 |
| Administrator’s telephone number | 2563818200 |
Signature of
| Role | Plan administrator |
| Date | 2013-06-19 |
| Name of individual signing | JACKIE GROSS |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 1989-01-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 2563818200 |
| Plan sponsor’s address | 1100 SOUTH MONTGOMERY AVENUE, SHEFFIELD, AL, 35660 |
Plan administrator’s name and address
| Administrator’s EIN | 630991793 |
| Plan administrator’s name | J. ANDRE TAYLOR, M.D. |
| Plan administrator’s address | 1100 SOUTH MONTGOMERY AVENUE, SHEFFIELD, AL, 35660 |
| Administrator’s telephone number | 2563818200 |
Signature of
| Role | Plan administrator |
| Date | 2012-10-15 |
| Name of individual signing | JACKIE GROSS |
| File | View Page |
| Three-digit plan number (PN) | 001 |
| Effective date of plan | 1989-01-01 |
| Business code | 621111 |
| Sponsor’s telephone number | 2563818200 |
| Plan sponsor’s address | 1100 SOUTH MONTGOMERY AVENUE, SHEFFIELD, AL, 35660 |
Plan administrator’s name and address
| Administrator’s EIN | 630991793 |
| Plan administrator’s name | J. ANDRE TAYLOR, M.D. |
| Plan administrator’s address | 1100 SOUTH MONTGOMERY AVENUE, SHEFFIELD, AL, 35660 |
| Administrator’s telephone number | 2563818200 |
Signature of
| Role | Plan administrator |
| Date | 2011-10-12 |
| Name of individual signing | JACKIE GROSS |
| Name | Role | Address |
|---|---|---|
| TAYLOR, J ANDRE | Agent | 1100 SOUTH JACKSON HWY SUITE 150SHEFFIELD, AL 35660 |
| Name | Role | Address |
|---|---|---|
| TAYLOR, J ANDRE | Member | 1100 SOUTH JACKSON HWY SUITE 150SHEFFIELD, AL 35660 |
Date of last update: 15 Aug 2024
Sources: Alabama Secretary of State
