=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497962906
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILLIP FREDERICK FORTMEYER D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2007
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 SOUTHLAND DR STE 100
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35226-3710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-822-4325
-----------------------------------------------------
Fax | 205-822-4330
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1016 WICKFORD RD
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35216-2317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-822-7213
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1161
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------