Basic Information
| Provider Information | |||||||||
| NPI: | 1962453852 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STOVER | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | ROGER | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 415 | ||||||||
| Address2: | |||||||||
| City: | MC INTOSH | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365530415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2519442842 | ||||||||
| FaxNumber: | 2519448070 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 HIGHWAY 43 NORTH | ||||||||
| Address2: | |||||||||
| City: | MCINTOSH | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2519442842 | ||||||||
| FaxNumber: | 2519448070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 03/03/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 13892 | AL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1962453852 | 01 | AL | NPI | OTHER | 51591327 | 01 | AL | BLUE SHIELD | OTHER | 631502023 | 05 | AL | MEDICAID |