Basic Information
| Provider Information | |||||||||
| NPI: | 1558579375 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALMODOVAR-RETEGUIS | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 55310 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352555310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057319701 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2000 6TH AVE S | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352332110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2058018000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 01/09/2012 | ||||||||
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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 | 207U00000X | 060347 | GA | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | 207U00000X | 31018 | AL | Y | Allopathic & Osteopathic Physicians | Nuclear Medicine |
ID Information
| ID | Type | State | Issuer | Description | 051120025 | 01 | AL | BCBS | OTHER | Z21039 | 01 | AL | VIVA | OTHER | 051120021 | 01 | AL | BCBS | OTHER | 131213 | 05 | AL | MEDICAID | 131215 | 05 | AL | MEDICAID | 131226 | 05 | AL | MEDICAID | 051120018 | 01 | AL | BCBS | OTHER | 051120026 | 01 | AL | BCBS | OTHER | 131220 | 05 | AL | MEDICAID | 131224 | 05 | AL | MEDICAID | 051120022 | 01 | AL | BCBS | OTHER | 09770524 | 05 | MS | MEDICAID | 131219 | 05 | AL | MEDICAID | 131222 | 05 | AL | MEDICAID | 131228 | 05 | AL | MEDICAID | 51120027 | 01 | AL | BCBS | OTHER | 051120019 | 01 | AL | BCBS | OTHER | 051120023 | 01 | AL | BCBS | OTHER | 051120024 | 01 | AL | BCBS | OTHER | 051120028 | 01 | AL | BCBS | OTHER | 131212 | 05 | AL | MEDICAID | 131217 | 05 | AL | MEDICAID |