Provider Demographics
NPI:1366794208
Name:THE ADULT MEDICAL SPECIALIST, PC
Entity type:Organization
Organization Name:THE ADULT MEDICAL SPECIALIST, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:GLYMPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-277-6645
Mailing Address - Street 1:81 MARKET PL
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-4908
Mailing Address - Country:US
Mailing Address - Phone:334-277-6645
Mailing Address - Fax:334-277-8985
Practice Address - Street 1:81 MARKET PL
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-4908
Practice Address - Country:US
Practice Address - Phone:334-277-6645
Practice Address - Fax:334-277-8985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-02
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12216261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC73387Medicare UPIN