Provider Demographics
NPI:1811089808
Name:DRS SIMON & MEDLOCK PRTNR
Entity type:Organization
Organization Name:DRS SIMON & MEDLOCK PRTNR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MEDLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:205-560-0477
Mailing Address - Street 1:PO BOX 360064
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35236-0064
Mailing Address - Country:US
Mailing Address - Phone:205-560-0477
Mailing Address - Fax:205-560-0477
Practice Address - Street 1:832 PRINCETON AVE SW
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211-1320
Practice Address - Country:US
Practice Address - Phone:205-780-7053
Practice Address - Fax:205-206-8368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS587TA195; S592TA197152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALE659OtherMEDICARE GROUP NUMBER
ALE659OtherMEDICARE GROUP NUMBER
AL25841Medicare PIN
ALT69064Medicare UPIN
ALT87426Medicare UPIN