Healthcare Provider Details

I. General information

NPI: 1407361108
Provider Name (Legal Business Name): WILLOW TREE PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 AL HIGHWAY 157
CULLMAN AL
35058-0656
US

IV. Provider business mailing address

1641 EDGEWOOD ST NW
CULLMAN AL
35055-5739
US

V. Phone/Fax

Practice location:
  • Phone: 256-735-4632
  • Fax: 256-735-4639
Mailing address:
  • Phone: 256-708-6143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number19923
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier138096
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer

VIII. Authorized Official

Name: DR. HEIDI BLAIR
Title or Position: PROVIDER/OWNER
Credential: MD
Phone: 256-708-6143