Basic Information
| Provider Information | |||||||||
| NPI: | 1144350349 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDER NOOT | ||||||||
| FirstName: | ROSS | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 619 19TH ST S | ||||||||
| Address2: | OHB 251 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352491900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059757387 | ||||||||
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| Practice Location | |||||||||
| Address1: | 619 19TH ST S | ||||||||
| Address2: | OHB 251 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352491900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059757387 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 10/09/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 127063 | NC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD.28863 | AL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 103334 | 05 | AL | MEDICAID | 515-92504 | 01 | AL | BCBS | OTHER | 1144350349 | 01 | AL | TRICARE SOUTH | OTHER | 111042 | 05 | AL | MEDICAID |