Basic Information
| Provider Information | |||||||||
| NPI: | 1275598658 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STANFORD | ||||||||
| FirstName: | GEORGIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 635 W COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356305313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567643431 | ||||||||
| FaxNumber: | 2567652036 | ||||||||
| Practice Location | |||||||||
| Address1: | 635 W COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356305313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567643431 | ||||||||
| FaxNumber: | 2567652036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 07/11/2007 | ||||||||
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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 | 2084P0800X | 10187 | AL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1508822313 | 01 | AL | GROUP NPI NUMBER | OTHER | D078 | 01 | AL | MEDICARE GROUP NUMBER | OTHER | 051553241 | 05 | AL | MEDICAID |