Basic Information
| Provider Information | |||||||||
| NPI: | 1942252846 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IRVING | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | WALTER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5320 HWY 90 SERVICE ROAD | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516021667 | ||||||||
| FaxNumber: | 2516025660 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 MEDICAL PARK DR | ||||||||
| Address2: | BLDG 1 STE 102 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366933318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516658060 | ||||||||
| FaxNumber: | 2516658061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 09/05/2013 | ||||||||
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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 | 208D00000X | 8971 | AL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 000015855 | 01 | AL | MEDICARE | OTHER | 051015855 | 01 | BCBS | OTHER |