=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093825127
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROOSEVELT MCCORVEY M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2455 BELL RD
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36117-4336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-747-8980
-----------------------------------------------------
Fax | 334-747-8970
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 BROWN SPRINGS RD
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36117-7005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-273-4159
-----------------------------------------------------
Fax | 334-273-4290
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | MD.7451
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------