Provider Demographics
NPI:1679528186
Name:STIDHAM MEDICAL, LLC
Entity type:Organization
Organization Name:STIDHAM MEDICAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:STIDHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-739-1233
Mailing Address - Street 1:1890 AL HIGHWAY 157 STE 220
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35058-0689
Mailing Address - Country:US
Mailing Address - Phone:256-739-1233
Mailing Address - Fax:256-734-5129
Practice Address - Street 1:1890 AL HIGHWAY 157 STE 220
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35058-0689
Practice Address - Country:US
Practice Address - Phone:256-739-1233
Practice Address - Fax:256-734-5129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000032914Medicaid
AL000032914Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER