Provider Demographics
NPI:1558338236
Name:HALE, BERNARD THEOTIS (MD)
Entity Type:Individual
Prefix:MR
First Name:BERNARD
Middle Name:THEOTIS
Last Name:HALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BERNARD
Other - Middle Name:
Other - Last Name:HALE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2147 RIVERCHASE OFFICE RD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35244-1836
Mailing Address - Country:US
Mailing Address - Phone:205-403-8902
Mailing Address - Fax:205-982-0278
Practice Address - Street 1:2936 MARTI LANE
Practice Address - Street 2:AMERICAN FAMILY CARE INC
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116
Practice Address - Country:US
Practice Address - Phone:334-288-0088
Practice Address - Fax:334-288-2071
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13622207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51093135OtherBLUE CROSS BLUE SHIELD
AL51093135OtherBLUE CROSS BLUE SHIELD
AL93132Medicare ID - Type Unspecified