Healthcare Provider Details

I. General information

NPI: 1730874249
Provider Name (Legal Business Name): DILLON MICHAEL TATE NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2930 AL-237
PHIL CAMPBELL AL
35581
US

IV. Provider business mailing address

2930 AL -237
PHIL CAMPBELL AL
35581
US

V. Phone/Fax

Practice location:
  • Phone: 205-993-5642
  • Fax: 205-993-5926
Mailing address:
  • Phone: 205-993-5642
  • Fax: 205-993-5926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3-001403
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number906197
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: