Basic Information
| Provider Information | |||||||||
| NPI: | 1639352388 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RICHARD A. VALENTINE MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1615 21ST CT | ||||||||
| Address2: | |||||||||
| City: | PHENIX CITY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368673727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342974883 | ||||||||
| FaxNumber: | 3342977937 | ||||||||
| Practice Location | |||||||||
| Address1: | 1615 21ST CT | ||||||||
| Address2: | |||||||||
| City: | PHENIX CITY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368673727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342974883 | ||||||||
| FaxNumber: | 3342977937 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2007 | ||||||||
| LastUpdateDate: | 12/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | VALENTINE | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 3342974883 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 8450 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 515-13286 | 01 | AL | BCBSAL | OTHER |