Healthcare Provider Details

I. General information

NPI: 1679555940
Provider Name (Legal Business Name): BEVERLY J STICKLES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 03/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 MADISON ST SE
HUNTSVILLE AL
35801-4408
US

IV. Provider business mailing address

PO BOX 288
HUNTSVILLE AL
35804-0288
US

V. Phone/Fax

Practice location:
  • Phone: 256-880-6711
  • Fax: 256-880-6712
Mailing address:
  • Phone: 256-880-6711
  • Fax: 256-880-6712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number160790
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: