Basic Information
| Provider Information | |||||||||
| NPI: | 1124271283 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VIP MEDICAL SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1012 IRVING RD | ||||||||
| Address2: | |||||||||
| City: | HOMEWOOD | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352093428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054270691 | ||||||||
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| Practice Location | |||||||||
| Address1: | 608 STONE AVENUE | ||||||||
| Address2: | |||||||||
| City: | TALLADEGA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356102217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054270691 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2008 | ||||||||
| LastUpdateDate: | 06/24/2011 | ||||||||
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| AuthorizedOfficialLastName: | ROAN | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2054270691 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LC0200X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 128722 | 05 | AL | MEDICAID |