Provider Demographics
NPI:1528150851
Name:RETINA SPECIALISTS OF WEST ALABAMA LLC
Entity type:Organization
Organization Name:RETINA SPECIALISTS OF WEST ALABAMA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:205-343-0003
Mailing Address - Street 1:2101 HIGHLAND AVE S STE 350
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-4009
Mailing Address - Country:US
Mailing Address - Phone:205-558-2525
Mailing Address - Fax:205-558-2554
Practice Address - Street 1:500 HARGROVE RD E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-3751
Practice Address - Country:US
Practice Address - Phone:205-343-0003
Practice Address - Fax:205-343-0029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529931100Medicaid