NPIMap

Organization Active NPI

South Alabama Medical Clinic, LLC

  • Rural Health Clinic/Center
  • Grand Bay, AL
National Provider Identifier
1811288038
Registry record updated Aug 29, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
SOUTH ALABAMA MEDICAL CLINIC, LLC
Practice address
10075 Grand Bay Wilmer Rd S
Grand Bay, AL 36541-5003
Phone
(251) 865-1852
Fax
(251) 865-1854
NPI assigned
Apr 21, 2011
Reactivated
Jul 31, 2024
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 29, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Bridgot Peters
Title
Director
Phone
(251) 445-7618

Specialties & licenses 8

Specialty (taxonomy)CodeLicenseStatePrimary
Professional CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YP2500X
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X
General Practice PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208D00000X 1-072232 AL
Adult Mental Health Clinic/Center 261QM0850X
Adolescent and Children Mental Health Clinic/Center 261QM0855X
Rural Health Clinic/Center 261QR1300X AL Primary
Psychiatric/Mental Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LP0808X

Addresses

Primary practice location

10075 Grand Bay Wilmer Rd S
Grand Bay, AL 36541-5003

Mailing address

10075 Grand Bay Wilmer Rd S
Grand Bay, AL 36541-5003
Phone (251) 865-1852

Other identifiers 2

IdentifierTypeStateIssuer
140171OtherALRURAL HEALTH MEDICAID
129323MedicaidAL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20110622000356 AL Part B Supplier - Clinic/Group Practice 0345428363 Receives reassigned benefits from 23 practitioners
Practice locations: Grand Bay, AL
O20120214000520 AL Part A Provider - Rural Health Clinic 0345428363 Practice locations: Grand Bay, AL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1811288038. Details of each certification follow.

Rural health clinic certification: CCN 013966

Legal name
SOUTH ALABAMA MEDICAL CLINIC, LLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 25, 2012
Last certification
Mar 22, 2018
Ownership / control type
1C
Organization structure
LLCProprietary
Incorporated
Mar 29, 2011 in AL
Enrollment address
10075 Grand Bay Wilmer Road S
Grand Bay, AL 36541-5003

National Provider Directory

National Provider Directory
Tax ID family
South Alabama Medical Clinic2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 7

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Dorothy Shannon Waters-Hwang Individual 5% Or Greater Direct Ownership InterestPartner Jul 1, 2011 20%
Cherri Bedwell Individual W-2 Managing EmployeeOffice Manager Jul 1, 2011
Bridgot Peters Individual Corporate DirectorBilling Director Jan 1, 2012
W-2 Managing EmployeeBilling Director Jan 1, 2012
Lloyd S Stokes Individual 5% Or Greater Direct Ownership InterestPartner Jul 1, 2011 40%
Marissa Jadick Individual W-2 Managing EmployeeCredentialing Jan 1, 2024
Robert E Vickers Individual 5% Or Greater Direct Ownership InterestPartner Jul 1, 2011 20%
Darren Waters Individual 5% Or Greater Direct Ownership InterestPartner Jul 1, 2011 20%

Owners & managing parties with NPI records 4

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 23

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 23

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1303344000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1724889600000",
    "number": "1811288038",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10075 GRAND BAY WILMER RD S",
            "city": "GRAND BAY",
            "state": "AL",
            "postal_code": "365415003",
            "telephone_number": "251-865-1852",
            "fax_number": "251-865-1854"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10075 GRAND BAY WILMER RD S",
            "city": "GRAND BAY",
            "state": "AL",
            "postal_code": "365415003",
            "telephone_number": "251-865-1852",
            "fax_number": "251-865-1854"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH ALABAMA MEDICAL CLINIC, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-04-21",
        "last_updated": "2024-08-29",
        "certification_date": "2024-08-29",
        "deactivation_date": "2024-07-23",
        "reactivation_date": "2024-07-31",
        "status": "A",
        "authorized_official_last_name": "PETERS",
        "authorized_official_first_name": "BRIDGOT",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "251-445-7618"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Professional",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "General Practice",
            "state": "AL",
            "license": "1-072232",
            "primary": false
        },
        {
            "code": "261QM0850X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adult Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM0855X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adolescent and Children Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "AL",
            "license": null,
            "primary": true
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RURAL HEALTH MEDICAID",
            "identifier": "140171",
            "state": "AL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "129323",
            "state": "AL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Grand Bay, AL

Sources for this page

Verify at the official NPI Registry.