Healthcare Provider Details

I. General information

NPI: 1093907412
Provider Name (Legal Business Name): SOUTHEASTERN PEDIATRIC ASSOCIATES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2007
Last Update Date: 01/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

364 HONEYSUCKLE RD
DOTHAN AL
36305-1140
US

IV. Provider business mailing address

364 HONEYSUCKLE RD
DOTHAN AL
36305-1140
US

V. Phone/Fax

Practice location:
  • Phone: 334-794-8656
  • Fax: 337-702-7047
Mailing address:
  • Phone: 334-794-8656
  • Fax: 337-702-7047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier272658100
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer
# 2
Identifier528300110
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer

VIII. Authorized Official

Name: MRS. S. LUCY EVERETT
Title or Position: OFFICE MANAGER
Credential:
Phone: 334-794-8656