Basic Information
| Provider Information | |||||||||
| NPI: | 1811089808 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DRS SIMON & MEDLOCK PRTNR | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 360064 | ||||||||
| Address2: | |||||||||
| City: | HOOVER | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352360064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2055600477 | ||||||||
| FaxNumber: | 2055600477 | ||||||||
| Practice Location | |||||||||
| Address1: | 832 PRINCETON AVE SW | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352111320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057807053 | ||||||||
| FaxNumber: | 2052068368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 11/12/2010 | ||||||||
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| AuthorizedOfficialLastName: | MEDLOCK | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2055600477 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | S587TA195; S592TA197 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | E659 | 01 | AL | MEDICARE GROUP NUMBER | OTHER |