Basic Information
| Provider Information | |||||||||
| NPI: | 1083607618 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VALENTINE | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1615 21ST CT | ||||||||
| Address2: | |||||||||
| City: | PHENIX CITY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368673727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342974883 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1615 21ST CT | ||||||||
| Address2: | |||||||||
| City: | PHENIX CITY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368673727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342974883 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 12/18/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/23/2006 | ||||||||
| NPIReactivationDate: | 03/27/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 8450 | AL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 51513286 | 01 | AL | BCBS | OTHER |