Basic Information
| Provider Information | |||||||||
| NPI: | 1255481230 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INFECTIOUS DISEASE SPECIALISTS OF MTG PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 242848 | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361242848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342709914 | ||||||||
| FaxNumber: | 3342703195 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 PINE ST | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361060165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342938138 | ||||||||
| FaxNumber: | 3342938134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 07/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | BEDSOLE | ||||||||
| AuthorizedOfficialFirstName: | GLENN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT - OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3343248893 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 528801490 | 05 | AL | MEDICAID |