Basic Information
Provider Information | |||||||||
NPI: | 1073608626 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FLEISIG | ||||||||
FirstName: | WAYNE | ||||||||
MiddleName: | EVAN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3709 CRESTBROOK ROAD | ||||||||
Address2: |   | ||||||||
City: | BIRMINGHAM | ||||||||
State: | AL | ||||||||
PostalCode: | 35223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2059692963 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1600 7TH AVENUE SOUTH | ||||||||
Address2: | ACC SUITE 500 | ||||||||
City: | BIRMINGHAM | ||||||||
State: | AL | ||||||||
PostalCode: | 35233 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2059399193 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/03/2006 | ||||||||
LastUpdateDate: | 04/16/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 715 | AL | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | 715 | AL | N |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 510-46084 | 01 | AL | BCBS | OTHER | 515-01261 | 01 | AL | FEDERAL BC | OTHER | 00915130 | 05 | AL |   | MEDICAID | 1073608626 | 01 | AL | TRICARE SOUTH | OTHER | 510-46083 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | 510-46083 | 01 | AL | BCBS | OTHER | 101797 | 05 | AL |   | MEDICAID | 000046084 | 05 | AL |   | MEDICAID |