Provider Demographics
NPI:1124005673
Name:ELLIOTT, CLYDE DALE (MD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:DALE
Last Name:ELLIOTT
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 1:1022 1ST ST N
Mailing Address - Street 2:SUITE 500
Mailing Address - City:ALABASTER
Mailing Address - State:AL
Mailing Address - Zip Code:35007-8706
Mailing Address - Country:US
Mailing Address - Phone:205-663-5775
Mailing Address - Fax:205-664-2112
Practice Address - Street 1:1022 1ST ST N
Practice Address - Street 2:SUITE 500
Practice Address - City:ALABASTER
Practice Address - State:AL
Practice Address - Zip Code:35007-8706
Practice Address - Country:US
Practice Address - Phone:205-663-5775
Practice Address - Fax:205-664-2112
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6974207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051552706Medicaid
ALC71667Medicare UPIN
AL051552706Medicaid