Basic Information
| Provider Information | |||||||||
| NPI: | 1396894838 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROEBUCK | ||||||||
| FirstName: | MALCOLM | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1722 PINE ST | ||||||||
| Address2: | STE 503 | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361061103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342709914 | ||||||||
| FaxNumber: | 3342703195 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 PINE ST | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361060165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342627444 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 05/01/2013 | ||||||||
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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 | 207R00000X | 10626 | AL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000031424 | 05 | AL | MEDICAID | 51031424 | 01 | AL | BLUE CROSS | OTHER |