=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447668199
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRINCE EDWARD PEDIATRICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2014
-----------------------------------------------------
Last Update Date | 07/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1715 W 3RD ST
-----------------------------------------------------
City | FARMVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23901-2651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-315-0138
-----------------------------------------------------
Fax | 434-392-9748
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 97
-----------------------------------------------------
City | RICE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23966-0097
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-315-0138
-----------------------------------------------------
Fax | 434-392-9748
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYICIAN
-----------------------------------------------------
Name | DR. IBTEHAL AL-ANI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 434-315-0138
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 0101242689
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------