Provider Demographics
NPI:1396794830
Name:FAIRCLOTH, MICHAEL BRYAN (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRYAN
Last Name:FAIRCLOTH
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:P O BOX 55309
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1714 9TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-3606
Practice Address - Country:US
Practice Address - Phone:205-934-3581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL15983207Q00000X
AL15983207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051523273FAIOtherBLUE CROSS BLUE SHIELD
AL051540413OtherBCBS
AL009941842Medicaid
AL051540412OtherBCBS
AL009941841Medicaid
AL510I080004Medicare PIN
AL051540413OtherBCBS
AL009941842Medicaid