Healthcare Provider Details

I. General information

NPI: 1508052168
Provider Name (Legal Business Name): EARL RAY STEWART JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 11/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27340 HIGHWAY 86
GORDO AL
35466-3578
US

IV. Provider business mailing address

14024 PRINCE WILLIAM WAY
NORTHPORT AL
35475-3670
US

V. Phone/Fax

Practice location:
  • Phone: 205-364-7135
  • Fax: 205-364-8244
Mailing address:
  • Phone: 205-364-7135
  • Fax: 205-364-8244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29112
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: