Healthcare Provider Details

I. General information

NPI: 1033158233
Provider Name (Legal Business Name): JEFFREY D BRASSART M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 WILL HALSEY WAY
MADISON AL
35758-2592
US

IV. Provider business mailing address

701 WILL HALSEY WAY
MADISON AL
35758-2592
US

V. Phone/Fax

Practice location:
  • Phone: 256-461-7440
  • Fax: 256-461-7168
Mailing address:
  • Phone: 256-461-7440
  • Fax: 256-461-7168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12787
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000031911
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer
# 2
Identifier0000120055505
Identifier TypeOTHER
Identifier StateAL
Identifier IssuerUNITED HEALTHCARE
# 3
Identifier51031911
Identifier TypeOTHER
Identifier StateAL
Identifier IssuerALABAMA BLUE CROSS
# 4
Identifier4259162
Identifier TypeOTHER
Identifier StateAL
Identifier IssuerAETNA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: