Basic Information
| Provider Information | |||||||||
| NPI: | 1497713200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMPLE | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | LESLIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4371 NARROW LANE RD | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361162975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3346133680 | ||||||||
| FaxNumber: | 3346133685 | ||||||||
| Practice Location | |||||||||
| Address1: | 4371 NARROW LANE RD | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361162971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3346133680 | ||||||||
| FaxNumber: | 3346133685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 03/27/2008 | ||||||||
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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 | 207Q00000X | DO898 | AL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 009937494 | 05 | AL | MEDICAID | 0403254 | 01 | AL | UNITED HEALTHCARE | OTHER | 630813275 | 01 | AL | COMMERCIAL | OTHER | 051557580 | 01 | AL | MEDICARE PROVIDER # | OTHER | 051542076 | 01 | AL | BCBS PROVIDER # | OTHER |