Basic Information
| Provider Information | |||||||||
| NPI: | 1992742860 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEDIATRIC RURAL HEALTH CLINICS, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GREENVILLE PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 46 L V STABLER DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360373804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343829760 | ||||||||
| FaxNumber: | 3343839331 | ||||||||
| Practice Location | |||||||||
| Address1: | 46 L V STABLER DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360373804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343829760 | ||||||||
| FaxNumber: | 3343839331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 10/11/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KEEN | ||||||||
| AuthorizedOfficialFirstName: | ANNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3343829760 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CRNP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 00006213 | AL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 00024891 | AL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 00006634 | AL | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363LP0200X | 01-069655 | AL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 1-065300 | AL | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 541003905 | 05 | AL | MEDICAID | 529800610 | 05 | AL | MEDICAID |