Basic Information
| Provider Information | |||||||||
| NPI: | 1063520591 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIBANDA | ||||||||
| FirstName: | GEROLD | ||||||||
| MiddleName: | NOEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12366 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352022366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057807101 | ||||||||
| FaxNumber: | 2052068338 | ||||||||
| Practice Location | |||||||||
| Address1: | 832 PRINCETON AVE SW | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352111320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2052068460 | ||||||||
| FaxNumber: | 2052068380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 10/01/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 00021802 | AL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 630506063 | 05 | AL | MEDICAID | 51212983 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | 51514660SIB | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER |