1558338236 NPI number — MR. BERNARD THEOTIS HALE MD

Table of content: MR. BERNARD THEOTIS HALE MD (NPI 1558338236)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558338236 NPI number — MR. BERNARD THEOTIS HALE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HALE
Provider First Name:
BERNARD
Provider Middle Name:
THEOTIS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HALE
Provider Other First Name:
BERNARD
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1558338236
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2147 RIVERCHASE OFFICE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35244-1836
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-403-8902
Provider Business Mailing Address Fax Number:
205-982-0278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2936 MARTI LANE
Provider Second Line Business Practice Location Address:
AMERICAN FAMILY CARE INC
Provider Business Practice Location Address City Name:
MONTGOMERY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-288-0088
Provider Business Practice Location Address Fax Number:
334-288-2071
Provider Enumeration Date:
03/02/2006

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:  13622 , 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: 51093135 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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