Healthcare Provider Details

I. General information

NPI: 1427252766
Provider Name (Legal Business Name): MEDPEDS OF DOTHAN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 WESTGATE PKWY STE 2
DOTHAN AL
36303-2963
US

IV. Provider business mailing address

318 WESTGATE PARKWAY STE 2
DOTHAN AL
36303
US

V. Phone/Fax

Practice location:
  • Phone: 334-671-2895
  • Fax: 334-712-9430
Mailing address:
  • Phone: 334-671-2895
  • Fax: 334-712-9430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number00024928
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number00024928
License Number StateAL

VIII. Authorized Official

Name: KRISTIN BOUTWELL
Title or Position: ADMINISTRATION
Credential:
Phone: 334-671-2895