Provider Demographics
NPI:1982668828
Name:PRIME, DARRYL DWAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:DARRYL
Middle Name:DWAYNE
Last Name:PRIME
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 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:205-731-9701
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:35249-2008
Practice Address - Country:US
Practice Address - Phone:205-934-4011
Practice Address - Fax:205-297-9411
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-00624207R00000X
AL00025739207R00000X
AL25739207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC14408OtherBLUECROSSBLUESHIELD
AL009997315Medicaid
NC5905885Medicaid
AL009997315Medicaid
AL102I062305Medicare PIN
AL051527609Medicare ID - Type Unspecified
NC2063160Medicare PIN
ALI27465Medicare UPIN