Provider Demographics
NPI:1699709378
Name:EBERLY, GARY ALLEN (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:ALLEN
Last Name:EBERLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 EAST LAUREL AVENUE
Mailing Address - Street 2:
Mailing Address - City:FOLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36535-2248
Mailing Address - Country:US
Mailing Address - Phone:251-943-7901
Mailing Address - Fax:251-943-1949
Practice Address - Street 1:1090 EAST LAUREL AVENUE
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-2248
Practice Address - Country:US
Practice Address - Phone:251-943-7901
Practice Address - Fax:251-943-1949
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21260208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL154115Medicaid
AL051501693EBEMedicare ID - Type Unspecified
AL154115Medicaid