Healthcare Provider Details

I. General information

NPI: 1962974147
Provider Name (Legal Business Name): MACON OVERTON III NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. CHIP OVERTON

II. Dates (important events)

Enumeration Date: 12/28/2018
Last Update Date: 12/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 GOVERNORS DR SE
HUNTSVILLE AL
35801-2700
US

IV. Provider business mailing address

137 DANIKA DR NW
HUNTSVILLE AL
35806-4119
US

V. Phone/Fax

Practice location:
  • Phone: 256-265-7946
  • Fax:
Mailing address:
  • Phone: 601-540-8782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number1-171815
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: