| Name: | Med 360 Urgent Care Northport, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Professional Limited Liability Company |
| Status: | Exists |
| Date of registration: | 16 Jun 2021 (4 years ago) |
| Entity Number: | 000-868-039 |
| Register Number: | 000868039 |
| ZIP code: | 35594 |
| County: | Marion |
| Place of Formation: | Marion County |
| Registered Office Street Address: | 125 BOB LAWRENCE ROAD SUITE CWINFIELD, AL 35594 |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1073238747 | 2022-10-05 | 2024-10-08 | 3250 MCFARLAND BLVD STE A, NORTHPORT, AL, 354763135, US | 3250 MCFARLAND BLVD, NORTHPORT, AL, 354763135, US | |||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 205-632-3875 |
| Fax | 2054623056 |
| Phone | +1 205-487-4535 |
| Fax | 2054878875 |
Authorized person
| Name | DR. FAROUK A RAQUIB |
| Role | OWNER/ MD |
| Phone | 2053263875 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 322964 |
| State | AL |
| Issuer | BCBS |
| Number | 512-92816 |
| State | AL |
| Issuer | NPI |
| Number | 1477511194 |
| State | AL |
| Issuer | MEDICAID |
| Number | 315872 |
| State | AL |
| Name | Role | Address |
|---|---|---|
| FAROUK RAQUIB | Agent | 125 BOB LAWRENCE ROAD SUITE CWINFIELD, AL 35594 |
| Name | Role | Address |
|---|---|---|
| FAROUK RAQUIB | Organizer | 125 BOB LAWRENCE ROAD SUITE CWINFIELD, AL 35594 |
Date of last update: 16 Aug 2024
Sources: Alabama Secretary of State
