Basic Information
| Provider Information | |||||||||
| NPI: | 1093771180 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | WESLEY | ||||||||
| MiddleName: | OMAR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 AFFLINK PL | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354062289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053669740 | ||||||||
| FaxNumber: | 2053449992 | ||||||||
| Practice Location | |||||||||
| Address1: | 1780 MCFARLAND BLVD N | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354062136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053457351 | ||||||||
| FaxNumber: | 2053458476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 07/24/2008 | ||||||||
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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 | 174400000X | 5726 | AL | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 529800880 | 05 | AL | MEDICAID |