Basic Information
| Provider Information | |||||||||
| NPI: | 1891734455 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DETRINIS | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5750A SOUTHLAND DR | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366933316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514505916 | ||||||||
| FaxNumber: | 2516627297 | ||||||||
| Practice Location | |||||||||
| Address1: | 7400 ROPER LN | ||||||||
| Address2: | |||||||||
| City: | DAPHNE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365265274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514502211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | LA9582R | LA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | MD.44998 | AL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1962520 | 05 | LA | MEDICAID |