Basic Information
| Provider Information | |||||||||
| NPI: | 1225036312 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANDY | ||||||||
| FirstName: | ROY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GANDY | ||||||||
| OtherFirstName: | ROY | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| 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: | MASTIN 101 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366172238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514458282 | ||||||||
| FaxNumber: | 2514458281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 07/01/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/16/2006 | ||||||||
| NPIReactivationDate: | 03/21/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 6662 | AL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 277823800 | 05 | FL | MEDICAID | 51539457 | 01 | AL | BCBS 1720 CENTER ST | OTHER | 000008042 | 05 | AL | MEDICAID | 5108042 | 01 | AL | BCBS | OTHER | 51539539 | 01 | AL | BCBS 575 STANTON | OTHER | 009941402 | 05 | AL | MEDICAID | 009941403 | 05 | AL | MEDICAID | 00501046 | 05 | MS | MEDICAID |