Healthcare Provider Details

I. General information

NPI: 1790280147
Provider Name (Legal Business Name): FREDDY B DILLARD JR. PA-S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 PRINCETON AVE SW
BIRMINGHAM AL
35211-1303
US

IV. Provider business mailing address

P.O. BOX 830550 MSC100
BIRMINGHAM AL
35283-0550
US

V. Phone/Fax

Practice location:
  • Phone: 205-977-1949
  • Fax: 412-822-7411
Mailing address:
  • Phone: 800-655-2656
  • Fax: 412-822-7411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.1313
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: