Healthcare Provider Details

I. General information

NPI: 1093039562
Provider Name (Legal Business Name): ADOLESCENT AND PEDIATRIC MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2010
Last Update Date: 03/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1638 N PLAZA DR
TALLAHASSEE FL
32308-5323
US

IV. Provider business mailing address

1638 N PLAZA DR
TALLAHASSEE FL
32308-5323
US

V. Phone/Fax

Practice location:
  • Phone: 850-878-5147
  • Fax: 850-942-9844
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberME39184
License Number StateFL

VIII. Authorized Official

Name: DR. LIONEL HENRY
Title or Position: OWNER/DOCTOR
Credential: M.D.
Phone: 850-878-5147