Basic Information
| Provider Information | |||||||||
| NPI: | 1447439237 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ABC PEDIATRIC CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 MAIN AVE SW | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350557200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567343759 | ||||||||
| FaxNumber: | 2567349764 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 MAIN AVE SW | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350557200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567343759 | ||||||||
| FaxNumber: | 2567349764 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2007 | ||||||||
| LastUpdateDate: | 03/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | JOINES | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | KAREN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2567343759 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | MD.23029 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 529916230 | 05 | AL | MEDICAID |