Basic Information
| Provider Information | |||||||||
| NPI: | 1144228388 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PYNES | ||||||||
| FirstName: | L | ||||||||
| MiddleName: | TERRY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PYNES | ||||||||
| OtherFirstName: | L | ||||||||
| OtherMiddleName: | TERRY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2431 W MAIN ST | ||||||||
| Address2: | STE 501 | ||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363011274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347939222 | ||||||||
| FaxNumber: | 3346710322 | ||||||||
| Practice Location | |||||||||
| Address1: | 2431 W MAIN ST | ||||||||
| Address2: | STE 501 | ||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347939222 | ||||||||
| FaxNumber: | 3346710322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 08/08/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/16/2006 | ||||||||
| NPIReactivationDate: | 03/23/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 8834 | AL | N | Allopathic & Osteopathic Physicians | Dermatology | 174400000X | 8834 | AL | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 000081148 | 05 | AL | MEDICAID |