Provider Demographics
NPI:1962453852
Name:STOVER, PHILLIP ROGER (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:ROGER
Last Name:STOVER
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:PO BOX 415
Mailing Address - Street 2:
Mailing Address - City:MC INTOSH
Mailing Address - State:AL
Mailing Address - Zip Code:36553-0415
Mailing Address - Country:US
Mailing Address - Phone:251-944-2842
Mailing Address - Fax:251-944-8070
Practice Address - Street 1:7777 HIGHWAY 43 NORTH
Practice Address - Street 2:
Practice Address - City:MCINTOSH
Practice Address - State:AL
Practice Address - Zip Code:36553
Practice Address - Country:US
Practice Address - Phone:251-944-2842
Practice Address - Fax:251-944-8070
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13892208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1962453852OtherNPI
AL51591327OtherBLUE SHIELD
AL631502023Medicaid
AL36354Medicare ID - Type Unspecified
AL631502023Medicaid