=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790844819
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHEAST PEDIATRICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 804 CRAWFORD ST
-----------------------------------------------------
City | TUSKEGEE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36083-7262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-724-0350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 804 CRAWFORD ST
-----------------------------------------------------
City | TUSKEGEE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36083-7262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-724-0350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFIICER
-----------------------------------------------------
Name | DR. MOLLIE ANN WALKER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 334-724-0550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 0011822
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------