Provider Demographics
NPI:1831183219
Name:STIDHAM, GREGORY P (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:P
Last Name:STIDHAM
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 1:110 23RD ST NW
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:AL
Mailing Address - Zip Code:35555-1001
Mailing Address - Country:US
Mailing Address - Phone:205-932-3891
Mailing Address - Fax:205-932-3996
Practice Address - Street 1:110 23RD ST NW
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:AL
Practice Address - Zip Code:35555-1001
Practice Address - Country:US
Practice Address - Phone:205-932-3891
Practice Address - Fax:205-932-3996
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00021977207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009928080Medicaid
AL630936460OtherTAX ID
AL000095990Medicare ID - Type Unspecified
AL630936460OtherTAX ID