Basic Information
Provider Information | |||||||||
NPI: | 1881676708 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FAVRET | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | F | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9369 | ||||||||
Address2: |   | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366910369 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2514600326 | ||||||||
FaxNumber: | 2514602846 | ||||||||
Practice Location | |||||||||
Address1: | 750 MORPHY AVE | ||||||||
Address2: |   | ||||||||
City: | FAIRHOPE | ||||||||
State: | AL | ||||||||
PostalCode: | 365321812 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2519287205 | ||||||||
FaxNumber: | 2514602846 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2005 | ||||||||
LastUpdateDate: | 10/27/2016 | ||||||||
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 | 2085R0202X | 23227 | AL | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 51095177 | 01 | AL | BCBS OF ALA | OTHER | 159837 | 05 | AL |   | MEDICAID | 51145889 | 01 | AL | BCBS | OTHER |