Basic Information
Provider Information | |||||||||
NPI: | 1649254459 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ALALY | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3153 DEPT 30755 | ||||||||
Address2: |   | ||||||||
City: | BIRMINGHAM | ||||||||
State: | AL | ||||||||
PostalCode: | 352879283 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3142385260 | ||||||||
FaxNumber: | 3148211833 | ||||||||
Practice Location | |||||||||
Address1: | 1201 BISHOP ST | ||||||||
Address2: |   | ||||||||
City: | UNION CITY | ||||||||
State: | TN | ||||||||
PostalCode: | 382615403 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7318852410 | ||||||||
FaxNumber: | 3148211833 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/05/2005 | ||||||||
LastUpdateDate: | 12/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | R7629 | MO | Y |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
ID | Type | State | Issuer | Description | 140376000 | 01 |   | DEPT OF LABOR | OTHER | 201196136 | 05 | MO |   | MEDICAID | 4964V4964 | 01 |   | GHP | OTHER | P00133934 | 01 |   | TRAVELERS | OTHER | 431142188OSU | 01 |   | MERCY | OTHER | 112315 | 01 | MO | HEALTHLINK | OTHER | 1600251 | 01 |   | UHC | OTHER | 1765 | 01 | MO | BCBS | OTHER |