=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003296153
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALAN BARTHOLOMEW D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2015
-----------------------------------------------------
Last Update Date | 08/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 FISHER ST RM 1F325
-----------------------------------------------------
City | KEESLER AFB
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39534-2508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-706-4520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 88 MDG/SGHJ 4881 SUGAR MAPLE DR.
-----------------------------------------------------
City | WRIGHT PATTERSON AFB
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-257-6529
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | 1747
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | 1747
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------