Basic Information
| Provider Information | |||||||||
| NPI: | 1679555940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STICKLES | ||||||||
| FirstName: | BEVERLY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 288 | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358040288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568806711 | ||||||||
| FaxNumber: | 2568806712 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 MADISON ST SE | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358014408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568806711 | ||||||||
| FaxNumber: | 2568806712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 03/26/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 160790 | MA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 2000005 | 01 | MA | UNITED HEALTHCARE | OTHER | 2040590 | 05 | MA | MEDICAID | 613824 | 01 | MA | HARVARD PILGRIM HEALTHCAR | OTHER | 5586023 | 01 | MA | AETNA | OTHER | 469828 | 01 | MA | TUFTS HEALTHCARE | OTHER | J27289ST | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 82971 | 01 | MA | AETNA US HEALTHCARE | OTHER |