Basic Information
| Provider Information | |||||||||
| NPI: | 1518934140 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KETCHUM | ||||||||
| FirstName: | CAREY | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KETCHUM | ||||||||
| OtherFirstName: | CAREY | ||||||||
| OtherMiddleName: | W | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2147 RIVERCHASE OFFICE RD | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352441836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054038902 | ||||||||
| FaxNumber: | 2059820278 | ||||||||
| Practice Location | |||||||||
| Address1: | 1664 FORESTDALE BLVD | ||||||||
| Address2: | AMERICAN FAMILY CARE INC FORESTDALE CLINIC | ||||||||
| City: | FORESTDALE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057912273 | ||||||||
| FaxNumber: | 2057919753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 10232 | AL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 51590263 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | P00155440 | 01 | AL | RAILROAD MEDICARE | OTHER |