Basic Information
| Provider Information | |||||||||
| NPI: | 1295760494 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAIRHOPE INTERNAL MEDICINE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 S INGLESIDE ST STE 6 | ||||||||
| Address2: | |||||||||
| City: | FAIRHOPE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365321804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2519901740 | ||||||||
| FaxNumber: | 2519901831 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 S INGLESIDE ST STE 6 | ||||||||
| Address2: | |||||||||
| City: | FAIRHOPE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365321804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2519901740 | ||||||||
| FaxNumber: | 2519901831 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 06/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | RAY | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | SUSAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2519901740 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 529917330 | 05 | AL | MEDICAID |