MEDICARE: MR. THOMAS JOHN DAVIDSON III MD

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	207Q00000X	Family Medicine Physician	10519	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	51503998	OTHER	AL	BLUE CROSS AND BLUE SHIED

General Provider Information

NPI Number	:	1942319819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THOMAS JOHN DAVIDSON III MD

Provider Business Mailing Address
First Line	:	PO BOX 1859
Second Line	:
City	:	GULF SHORES
State	:	AL
Zip	:	36547-1859
Country	:	US
Telephone Number	:	251-968-7379
Fax Number	:	251-968-5960

Provider Business Practice Location Address
First Line	:	200 OFFICE PARK DRIVE
Second Line	:
City	:	GULF SHORES
State	:	AL
Zip	:	36542-3432
Country	:	US
Telephone Number	:	251-968-7379
Fax Number	:	251-968-5960

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	12/12/2007

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