Healthcare Provider Details

I. General information

NPI: 1104240324
Provider Name (Legal Business Name): MOBILE PEDIATRIC CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2014
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6321 PICCADILLY SQUARE DR STE A
MOBILE AL
36609-5305
US

IV. Provider business mailing address

PO BOX 91899
MOBILE AL
36691-1899
US

V. Phone/Fax

Practice location:
  • Phone: 251-342-8900
  • Fax: 251-342-2333
Mailing address:
  • Phone: 251-706-8170
  • Fax: 251-706-8098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: AMY COLLINS
Title or Position: OWNER
Credential:
Phone: 251-610-1618