Provider Demographics
NPI:1184652596
Name:BOBO, PHILLIP KELLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:KELLEY
Last Name:BOBO
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 1:32 15TH ST
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-3661
Mailing Address - Country:US
Mailing Address - Phone:205-345-2326
Mailing Address - Fax:205-345-0708
Practice Address - Street 1:32 15TH ST
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-3661
Practice Address - Country:US
Practice Address - Phone:205-345-2326
Practice Address - Fax:205-345-0708
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00006261207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
0133467OtherNATIONAL COUNCIL FOR PRES
C69956Medicare UPIN