Basic Information
Provider Information | |||||||||
NPI: | 1083619332 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JUSTICE | ||||||||
FirstName: | WILEY | ||||||||
MiddleName: | HUGH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 40277 | ||||||||
Address2: |   | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366880277 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2514459378 | ||||||||
FaxNumber: | 2514459377 | ||||||||
Practice Location | |||||||||
Address1: | 5721 USA NORTH DR | ||||||||
Address2: | HAHN 1119 | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366880002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2514459378 | ||||||||
FaxNumber: | 2514459377 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2005 | ||||||||
LastUpdateDate: | 06/04/2015 | ||||||||
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 | 207Y00000X | 00007930 | AL | Y |   | Allopathic & Osteopathic Physicians | Otolaryngology |   |
ID Information
ID | Type | State | Issuer | Description | 000034502 | 05 | AL |   | MEDICAID | 51511917 | 01 | AL | BLUE CROSS AL PROVIDER # | OTHER | 51034502 | 01 | AL | BLUE CROSS PROVIDER # | OTHER | C71226 | 01 | AL | HEALTHSPRING PROVIDER # | OTHER | 4006616 | 01 | AL | AETNA PROVIDER # | OTHER |