Provider Demographics
NPI:1760410849
Name:TAYLOR, BRUCE
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4258 US HIGHWAY 80 W
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701-2202
Mailing Address - Country:US
Mailing Address - Phone:334-874-8800
Mailing Address - Fax:334-874-7700
Practice Address - Street 1:4258 US HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-2202
Practice Address - Country:US
Practice Address - Phone:334-874-8800
Practice Address - Fax:334-874-7700
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL24464207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51516872OtherBC/BS
AL529916810Medicaid
AL01D1015085OtherCLIA
AL01D1015085OtherCLIA
AL529916810Medicaid
AL5620230001Medicare NSC
ALBT8368537OtherFEDERAL DEA