Healthcare Provider Details

I. General information

NPI: 1538347562
Provider Name (Legal Business Name): LORISSIA RENEA AUTERY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 BLACKWELL DAIRY RD
JASPER AL
35504-8406
US

IV. Provider business mailing address

3400 HIGHWAY 78 E SUITE 504
JASPER AL
35501-8907
US

V. Phone/Fax

Practice location:
  • Phone: 205-384-4801
  • Fax: 205-384-4538
Mailing address:
  • Phone: 205-384-0011
  • Fax: 205-384-4538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number31072
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: