MEDICARE: DR. GRANT PHILLIPS FOWLER OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	S-D80-TA-A80	AL

General Provider Information

NPI Number	:	1265957898
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GRANT PHILLIPS FOWLER OD

Provider Business Mailing Address
First Line	:	1520 MILITARY ST S
Second Line	:
City	:	HAMILTON
State	:	AL
Zip	:	35570-5006
Country	:	US
Telephone Number	:	205-921-5499
Fax Number	:

Provider Business Practice Location Address
First Line	:	1520 MILITARY ST S
Second Line	:
City	:	HAMILTON
State	:	AL
Zip	:	35570-5006
Country	:	US
Telephone Number	:	205-921-5499
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2017
Last Update Date	:	07/21/2022

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