Basic Information
Provider Information | |||||||||
NPI: | 1851357933 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | POORE | ||||||||
FirstName: | RAYMOND | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1400 AFFLINK PL | ||||||||
Address2: | SUITE 100 | ||||||||
City: | TUSCALOOSA | ||||||||
State: | AL | ||||||||
PostalCode: | 354062289 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2053669740 | ||||||||
FaxNumber: | 2053449992 | ||||||||
Practice Location | |||||||||
Address1: | 1780 MCFARLAND BLVD N | ||||||||
Address2: |   | ||||||||
City: | TUSCALOOSA | ||||||||
State: | AL | ||||||||
PostalCode: | 354062136 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2053457351 | ||||||||
FaxNumber: | 2053458476 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/26/2006 | ||||||||
LastUpdateDate: | 01/24/2014 | ||||||||
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 | 208800000X | 20891 | AL | Y |   | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 510-68253 | 01 | AL | BCBS OF AL | OTHER | 114258 | 05 | AL |   | MEDICAID | 114261 | 05 | AL |   | MEDICAID | 511-00713 | 01 | AL | BCBS OF AL | OTHER | 114264 | 05 | AL |   | MEDICAID | 510-68237 | 01 | AL | BCBS OF AL | OTHER | 510-68270 | 01 | AL | BCBS OF AL | OTHER | 114255 | 05 | AL |   | MEDICAID | 20891 | 01 | AL | MEDICAL LICENSE | OTHER |