Provider Demographics
NPI:1770552077
Name:TAYLOR, LARRY WAYNE
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:WAYNE
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LARRY
Other - Middle Name:W
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:2147 RIVERCHASE OFFICE RD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35244-1836
Mailing Address - Country:US
Mailing Address - Phone:205-403-8902
Mailing Address - Fax:205-982-7882
Practice Address - Street 1:6554 AARON DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:AL
Practice Address - Zip Code:35214
Practice Address - Country:US
Practice Address - Phone:205-786-5022
Practice Address - Fax:205-786-5028
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO453207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000027610Medicaid
AL051027665OtherBLUE CROSS BLUE SHIELD
AL080143157OtherRAILROAD MEDICARE
F83618Medicare UPIN
AL080143157OtherRAILROAD MEDICARE