Healthcare Provider Details

I. General information

NPI: 1770532681
Provider Name (Legal Business Name): MONTGOMERY PEDIATRIC ASSOC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 04/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 COTTON GIN RD
MONTGOMERY AL
36117-3557
US

IV. Provider business mailing address

420 COTTON GIN RD
MONTGOMERY AL
36117-3557
US

V. Phone/Fax

Practice location:
  • Phone: 334-260-9129
  • Fax: 334-260-9665
Mailing address:
  • Phone: 334-260-9129
  • Fax: 334-260-9665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number00006213
License Number StateAL

VIII. Authorized Official

Name: MRS. VIKKI BERRY
Title or Position: OFFICE MANAGER
Credential: OFFICE MANAGER
Phone: 334-260-9129