Healthcare Provider Details

I. General information

NPI: 1396884524
Provider Name (Legal Business Name): PEDIATRIC INTENSIVIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 LOWELL DR SE SUITE 14
HUNTSVILLE AL
35801-3748
US

IV. Provider business mailing address

401 LOWELL DR SE SUITE 14
HUNTSVILLE AL
35801-3748
US

V. Phone/Fax

Practice location:
  • Phone: 256-265-7791
  • Fax: 256-265-7767
Mailing address:
  • Phone: 256-265-7791
  • Fax: 256-265-7767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: HEATHER MASON
Title or Position: DIRECTOR OF PHYSICIANS NETWORK
Credential:
Phone: 256-265-7791