Provider Demographics
NPI:1043362734
Name:PHYSICAL EXPRESS
Entity type:Organization
Organization Name:PHYSICAL EXPRESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JADE
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-567-4311
Mailing Address - Street 1:PO BOX 688
Mailing Address - Street 2:
Mailing Address - City:MILLBROOK
Mailing Address - State:AL
Mailing Address - Zip Code:36054-0014
Mailing Address - Country:US
Mailing Address - Phone:334-285-3222
Mailing Address - Fax:334-285-6555
Practice Address - Street 1:4081 ALABAMA HWY 14
Practice Address - Street 2:
Practice Address - City:MILLBROOK
Practice Address - State:AL
Practice Address - Zip Code:36054
Practice Address - Country:US
Practice Address - Phone:334-285-3222
Practice Address - Fax:334-285-6555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALK505Medicare PIN