Healthcare Provider Details

I. General information

NPI: 1851978530
Provider Name (Legal Business Name): STANLEY GANT UNFRIED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2021
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27961 US HIGHWAY 98 STE 14
DAPHNE AL
36526-4725
US

IV. Provider business mailing address

27961 US HIGHWAY 98 STE 14
DAPHNE AL
36526-4725
US

V. Phone/Fax

Practice location:
  • Phone: 251-626-1175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL.5528R
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberL.5528R
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: