Healthcare Provider Details

I. General information

NPI: 1679515159
Provider Name (Legal Business Name): DERYCK A. JOSEPH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 01/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

832 PRINCETON AVE SW
BIRMINGHAM AL
35211-1320
US

IV. Provider business mailing address

PO BOX 12366
BIRMINGHAM AL
35202-2366
US

V. Phone/Fax

Practice location:
  • Phone: 205-206-8470
  • Fax: 205-206-8390
Mailing address:
  • Phone: 205-780-7101
  • Fax: 205-206-8338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number19217
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: