Basic Information
| Provider Information | |||||||||
| NPI: | 1073563508 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANNAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40480 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366400480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514705842 | ||||||||
| FaxNumber: | 2514705809 | ||||||||
| Practice Location | |||||||||
| Address1: | 2451 FILLINGIM ST | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366172238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514717150 | ||||||||
| FaxNumber: | 2514717008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 02/26/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 5625 | AL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 51526672 | 01 | AL | BCBS FILLINGIM | OTHER | 05400325 | 05 | MS | MEDICAID | 51526628 | 01 | AL | BCBS | OTHER | 372781500 | 05 | FL | MEDICAID | 009984055 | 05 | AL | MEDICAID | 16-01238 | 01 | AL | UNITED HEALTHCARE | OTHER | 1163112 | 05 | LA | MEDICAID | 009984045 | 05 | AL | MEDICAID | 51526744 | 01 | AL | BCBS SRC | OTHER |