Healthcare Provider Details

I. General information

NPI: 1073564670
Provider Name (Legal Business Name): RICHARD A LAUDERDALE JR. PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 12/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 TAYLOR RD
MONTGOMERY AL
36117-3512
US

IV. Provider business mailing address

301 BROWN SPRINGS RD
MONTGOMERY AL
36117-7005
US

V. Phone/Fax

Practice location:
  • Phone: 334-272-1050
  • Fax: 818-587-2493
Mailing address:
  • Phone: 334-273-4508
  • Fax: 334-273-4290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA151
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: