Healthcare Provider Details

I. General information

NPI: 1891766762
Provider Name (Legal Business Name): PEDIATRIC SPECIALISTS OF MONTGOMERY, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 MITYLENE PARK DR
MONTGOMERY AL
36117-3547
US

IV. Provider business mailing address

239 MITYLENE PARK DR
MONTGOMERY AL
36117-3547
US

V. Phone/Fax

Practice location:
  • Phone: 334-612-2111
  • Fax: 334-612-2166
Mailing address:
  • Phone: 334-612-2111
  • Fax: 334-612-2166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number16678
License Number StateAL

VIII. Authorized Official

Name: MEREDITH DAFFIN
Title or Position: ADMINISTRATOR
Credential:
Phone: 334-612-2111