Healthcare Provider Details

I. General information

NPI: 1962453852
Provider Name (Legal Business Name): PHILLIP ROGER STOVER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 03/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 HIGHWAY 43 NORTH
MCINTOSH AL
36553
US

IV. Provider business mailing address

PO BOX 415
MC INTOSH AL
36553-0415
US

V. Phone/Fax

Practice location:
  • Phone: 251-944-2842
  • Fax: 251-944-8070
Mailing address:
  • Phone: 251-944-2842
  • Fax: 251-944-8070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number13892
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: