Healthcare Provider Details

I. General information

NPI: 1356717631
Provider Name (Legal Business Name): PEDIATRIC PREVENTATIVE MEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2015
Last Update Date: 08/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6869 5TH AVE S
BIRMINGHAM AL
35212-1866
US

IV. Provider business mailing address

6869 5TH AVE S
BIRMINGHAM AL
35212-1866
US

V. Phone/Fax

Practice location:
  • Phone: 205-833-9000
  • Fax: 205-838-2073
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number30125
License Number StateAL

VIII. Authorized Official

Name: MARY HOLDEN JONES
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 205-552-8691