Basic Information
| Provider Information | |||||||||
| NPI: | 1396032983 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEARD | ||||||||
| FirstName: | WALTER | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1700 SPRING HILL AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366041416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514351200 | ||||||||
| FaxNumber: | 2514356357 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 SPRING HILL AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366041416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514351200 | ||||||||
| FaxNumber: | 2514356357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2011 | ||||||||
| LastUpdateDate: | 10/08/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| 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 | 207R00000X | T-2403 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | ME132982 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 81780 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | MD.36054 | AL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 81780 | 01 | GA | MEDICAL LICENSE | OTHER | ME132982 | 01 | FL | MEDICAL LICENSE | OTHER | T-2403 | 01 | MS | MS TEMPORARY MEDICAL LICENSE | OTHER | MD.36054 | 01 | AL | MEDICAL LICENSE | OTHER | 021429400 | 05 | FL | MEDICAID |