=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144315250
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHLAKE PEDIATRICS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 08/29/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4515 SOUTHLAKE PARKWAY SUITE 202
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 35244-3317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-982-2500
-----------------------------------------------------
Fax | 205-982-2574
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4515 SOUTHLAKE PARKWAY SUITE 202
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 35244-3317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-982-2500
-----------------------------------------------------
Fax | 205-982-2574
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/DIRECTOR
-----------------------------------------------------
Name | DR. ANDREW N MCCOWN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 205-982-2500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 16701
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------