Basic Information
| Provider Information | |||||||||
| NPI: | 1457708166 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUCKIE | ||||||||
| FirstName: | CORY | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4412 HOGAN RD | ||||||||
| Address2: | |||||||||
| City: | DEATSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360223400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3345434851 | ||||||||
| FaxNumber: | 3345434854 | ||||||||
| Practice Location | |||||||||
| Address1: | 850 PETER BRYCE BLVD | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354017419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053481770 | ||||||||
| FaxNumber: | 2053485294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2016 | ||||||||
| LastUpdateDate: | 12/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PT0002X | 36124 | AL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Medical Toxicology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 233383 | 05 | AL | MEDICAID |