Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204E00000X | Oral & Maxillofacial Surgeon | 20060 | AL |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 4438 | AL |
NPI | 1528101698 |
---|---|
Provider Name | Dr. Leroy A Kamelchuk |
First Address | Huntsville, AL 35801-6405 |
Second Address | Huntsville, AL 35801-6405 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/02/2007 |
Last Update Date | 16/08/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
51527421 | BLUE CROSS BLUE SHIELD (01) | AL |
G63091 | (02) | AL |