Basic Information
| Provider Information | |||||||||
| NPI: | 1760409874 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERALTA-CARCELEN | ||||||||
| FirstName: | ADA | ||||||||
| MiddleName: | MYRIAM | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PERALTA | ||||||||
| OtherFirstName: | MYRIAM | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 703 VOLKER HALL | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352940001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059343795 | ||||||||
| FaxNumber: | 2059752499 | ||||||||
| Practice Location | |||||||||
| Address1: | 1616 6TH AVE S | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352331788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059399096 | ||||||||
| FaxNumber: | 2059756503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 01/14/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 15068 | AL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000083222 | 05 | AL | MEDICAID | 1210029 | 01 | UHC | OTHER | 000028826 | 05 | AL | MEDICAID | 009999655 | 05 | AL | MEDICAID | 510-83222 | 01 | AL | BC BS | OTHER | E40209 | 01 | VIVA | OTHER |