Healthcare Provider Details

I. General information

NPI: 1861981102
Provider Name (Legal Business Name): BEAU TAYLOR VANDIVER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2018
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 HIGHWAY 280 S STE 300
MOUNTAIN BRK AL
35223-2445
US

IV. Provider business mailing address

3894 GRANTS LN
IRONDALE AL
35210-5510
US

V. Phone/Fax

Practice location:
  • Phone: 205-930-9595
  • Fax: 205-802-7719
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number39047
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: