1295772986 NPI number — DR. ROGER DALE STANMORE M.D.

Table of content: DR. ROGER DALE STANMORE M.D. (NPI 1295772986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295772986 NPI number — DR. ROGER DALE STANMORE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STANMORE
Provider First Name:
ROGER
Provider Middle Name:
DALE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295772986
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 303
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GADSDEN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35902-0303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-547-6119
Provider Business Mailing Address Fax Number:
256-546-2981

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7583 WALL TRIANA HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35757-8327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-547-6119
Provider Business Practice Location Address Fax Number:
256-546-2981
Provider Enumeration Date:
06/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  00013106 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3002 . This is a "NEIC SITE ID, NSF BA0-7" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51001283 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 3015 . This is a "NEIC SITE ID" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51532050 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: BS0874645 . This is a "DEA NUMBER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 009932569 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".