Provider Demographics
NPI:1255481230
Name:INFECTIOUS DISEASE SPECIALISTS OF MTG PC
Entity Type:Organization
Organization Name:INFECTIOUS DISEASE SPECIALISTS OF MTG PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT - OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BEDSOLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-324-8893
Mailing Address - Street 1:PO BOX 242848
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36124-2848
Mailing Address - Country:US
Mailing Address - Phone:334-270-9914
Mailing Address - Fax:334-270-3195
Practice Address - Street 1:1801 PINE ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-0165
Practice Address - Country:US
Practice Address - Phone:334-293-8138
Practice Address - Fax:334-293-8134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL528801490Medicaid
AL528801490Medicaid
ALI581Medicare PIN