Individual
DIAMOND VROCHER III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1806 SIXTH AVENUE SOUTH, BIRMINGHAM, AL 35249-0001
(205) 975-7389
(205) 975-4662
Mailing address
PO BOX 11407, DRAWER 624, BIRMINGHAM, AL 35246-0624
(205) 437-6098
(205) 437-5998
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
MD.25095
AL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
051553551
—
AL
05
—
106677
—
AL
01
—
1104808351
TRICARE SOUTH
AL
01
—
515-17086
BCBS
AL
01
—
515-94708
BCBS
AL
Enumeration date
11/15/2005
Last updated
03/12/2010
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