Basic Information
| Provider Information | |||||||||
| NPI: | 1003296153 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BARTHOLOMEW | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 88 MDG/SGHJ | ||||||||
| Address2: | 4881 SUGAR MAPLE DR. | ||||||||
| City: | WRIGHT PATTERSON AFB | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372576529 | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 FISHER ST RM 1F325 | ||||||||
| Address2: | |||||||||
| City: | KEESLER AFB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395342508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017064520 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2015 | ||||||||
| LastUpdateDate: | 08/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | 1747 | NE | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RR0500X | 1747 | NE | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 1747 | 05 | NE | MEDICAID |