Provider Demographics
NPI:1548438815
Name:ANDALUSIA GREATER REGIONAL OTOLARYNGOLOGY ENT P C
Entity type:Organization
Organization Name:ANDALUSIA GREATER REGIONAL OTOLARYNGOLOGY ENT P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICKEY
Authorized Official - Middle Name:G
Authorized Official - Last Name:LOVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-427-2476
Mailing Address - Street 1:300 MEDICAL AVENUE
Mailing Address - Street 2:2
Mailing Address - City:ANDALUSIA
Mailing Address - State:AL
Mailing Address - Zip Code:36420-1201
Mailing Address - Country:US
Mailing Address - Phone:334-427-2476
Mailing Address - Fax:334-427-2477
Practice Address - Street 1:300 MEDICAL AVENUE
Practice Address - Street 2:2
Practice Address - City:ANDALUSIA
Practice Address - State:AL
Practice Address - Zip Code:36420-1201
Practice Address - Country:US
Practice Address - Phone:334-427-2476
Practice Address - Fax:334-427-2477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12982174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529914990Medicaid
ALC53087Medicare UPIN
AL529914990Medicaid