Basic Information
| Provider Information | |||||||||
| NPI: | 1679570204 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAVAKOLI | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 55310 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352555310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057319701 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2010 BROOKWOOD MEDICAL CTR DR | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352096804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059891080 | ||||||||
| FaxNumber: | 2059891087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2005 | ||||||||
| LastUpdateDate: | 11/04/2011 | ||||||||
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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 | 207L00000X | 6173 | AL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 051594516 | 01 | AL | BCBS | OTHER | 101705 | 05 | AL | MEDICAID | 101704 | 05 | AL | MEDICAID | P00653636 | 01 | AL | RAILROAD MEDICARE | OTHER | 00003018 | 05 | AL | MEDICAID | 051549063 | 01 | AL | BCBS | OTHER | 101703 | 05 | AL | MEDICAID | C71588 | 01 | AL | VIVA | OTHER | 051549062 | 01 | AL | BCBS | OTHER | 051549064 | 01 | AL | BCBS | OTHER | 09259043 | 05 | MS | MEDICAID | 105513 | 05 | AL | MEDICAID |