Basic Information
Provider Information | |||||||||
NPI: | 1104813914 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RAGLAND | ||||||||
FirstName: | MARIE | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 11407 DRAWER 646 | ||||||||
Address2: |   | ||||||||
City: | BIRMINGHAM | ||||||||
State: | AL | ||||||||
PostalCode: | 352460001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2054376098 | ||||||||
FaxNumber: | 2054375998 | ||||||||
Practice Location | |||||||||
Address1: | 1600 7TH AVE S | ||||||||
Address2: |   | ||||||||
City: | BIRMINGHAM | ||||||||
State: | AL | ||||||||
PostalCode: | 352331711 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2059399587 | ||||||||
FaxNumber: | 2059754623 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2005 | ||||||||
LastUpdateDate: | 06/11/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD.23593 | AL | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 208000000X | MD.23593 | AL | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 009982960 | 05 | AL |   | MEDICAID | 1104813914 | 01 | AL | TRICARE SOUTH | OTHER | 009986210 | 05 | AL |   | MEDICAID | 515-07806 | 01 | AL | BCBS | OTHER | 515-07926 | 01 | AL | BCBS | OTHER | 7505501 | 01 | AL | AETNA | OTHER |