Healthcare Provider Details

I. General information

NPI: 1619661683
Provider Name (Legal Business Name): MR. DEREK ALAN PAYNE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 06/05/2023
Certification Date: 06/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1048 SHELANE CIR
BIRMINGHAM AL
35215-2924
US

IV. Provider business mailing address

1048 SHELANE CIR
BIRMINGHAM AL
35215-2924
US

V. Phone/Fax

Practice location:
  • Phone: 205-602-9617
  • Fax:
Mailing address:
  • Phone: 205-602-9617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number9137073539
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: