Basic Information
| Provider Information | |||||||||
| NPI: | 1558380410 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYATT | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | HARRIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 850489 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366850489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513423949 | ||||||||
| FaxNumber: | 2516313361 | ||||||||
| Practice Location | |||||||||
| Address1: | 5571 HIGHWAY 43 NORTH | ||||||||
| Address2: | |||||||||
| City: | SATSUMA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365720108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516752029 | ||||||||
| FaxNumber: | 2516753734 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 02/20/2012 | ||||||||
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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 | 174400000X | 00005880 | AL | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 511-16920 | 01 | AL | BLUE CROSS BLUE SHIELD OF ALABAMA | OTHER | 133632 | 05 | AL | MEDICAID | 051523637 | 01 | BC BS OF ALABAMA PROVIDER | OTHER |