Healthcare Provider Details

I. General information

NPI: 1528261518
Provider Name (Legal Business Name): STACEY DAVIS TATUM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 02/08/2012
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 NumberMD29320
License Number StateAL

VII. Legacy identifiers

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

# 1
Identifier630144587
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer
# 2
Identifier000118981
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: