Provider Demographics
NPI: | 1629191747 |
---|---|
Name: | OUTLER, KENDRA D (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | KENDRA |
Middle Name: | D |
Last Name: | OUTLER |
Suffix: | |
Gender: | F |
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: | PO BOX 55310 |
Mailing Address - Street 2: | |
Mailing Address - City: | BIRMINGHAM |
Mailing Address - State: | AL |
Mailing Address - Zip Code: | 35255-5310 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 619 19TH ST S |
Practice Address - Street 2: | |
Practice Address - City: | BIRMINGHAM |
Practice Address - State: | AL |
Practice Address - Zip Code: | 35249-0001 |
Practice Address - Country: | US |
Practice Address - Phone: | 205-731-9701 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-04-06 |
Last Update Date: | 2011-02-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
LA | 14642R | 207P00000X |
AL | 29842 | 207L00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | |
No | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
AL | 114989 | Medicaid | |
AL | 114991 | Medicaid | |
AL | 114988 | Medicaid | |
AL | 114987 | Medicaid | |
LA | 1127426 | Medicaid | |
LA | 1127426 | Medicaid | |
AL | 114987 | Medicaid | |
AL | 114988 | Medicaid |