MEDICARE: MS. LORISSIA RENEA AUTERY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	31072	AL

General Provider Information

NPI Number	:	1538347562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LORISSIA RENEA AUTERY M.D.

Provider Business Mailing Address
First Line	:	3400 HIGHWAY 78 E
Second Line	:	SUITE 504
City	:	JASPER
State	:	AL
Zip	:	35501-8907
Country	:	US
Telephone Number	:	205-384-0011
Fax Number	:	205-384-4538

Provider Business Practice Location Address
First Line	:	304 BLACKWELL DAIRY RD
Second Line	:
City	:	JASPER
State	:	AL
Zip	:	35504-8406
Country	:	US
Telephone Number	:	205-384-4801
Fax Number	:	205-384-4538

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2008
Last Update Date	:	04/08/2020

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