Healthcare Provider Details

I. General information

NPI: 1447823877
Provider Name (Legal Business Name): DOTHAN PEDIATRIC CLINIC, P. A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2021
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 BOLL WEEVIL CIR
ENTERPRISE AL
36330-4012
US

IV. Provider business mailing address

126 CLINIC DR
DOTHAN AL
36303-1980
US

V. Phone/Fax

Practice location:
  • Phone: 334-308-1166
  • Fax:
Mailing address:
  • Phone: 334-793-1881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: GINA TOLAR
Title or Position: INSURANCE & COLLECTIONS SUPERVISOR
Credential:
Phone: 334-793-1881