Basic Information
Provider Information | |||||||||
NPI: | 1619954153 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIS | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | EDWARD | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 235003 | ||||||||
Address2: |   | ||||||||
City: | MONTGOMERY | ||||||||
State: | AL | ||||||||
PostalCode: | 361235003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3342749000 | ||||||||
FaxNumber: | 3342740857 | ||||||||
Practice Location | |||||||||
Address1: | 4294 LOMAC ST | ||||||||
Address2: |   | ||||||||
City: | MONTGOMERY | ||||||||
State: | AL | ||||||||
PostalCode: | 361063604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3342749000 | ||||||||
FaxNumber: | 3342740857 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/27/2005 | ||||||||
LastUpdateDate: | 05/01/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 24900 | AL | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XS0117X | 24900 | AL | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
ID | Type | State | Issuer | Description | 009919875 | 05 | AL |   | MEDICAID | 51521459 | 01 |   | BLUE CROSS | OTHER | 7823416 | 01 |   | AETNA | OTHER | 09-10702 | 01 |   | UNITED HEALTHCARE | OTHER | 1053595165 | 01 |   | LOCATION NPI | OTHER | 14083 | 01 |   | NCC/TYNET | OTHER | 51516056 | 01 |   | BLUE CROSS | OTHER | 515 13453 | 01 |   | BLUE CROSS | OTHER | P00002536 | 01 |   | RR MEDICARE | OTHER |