MEDICARE: PEDIATRIC CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1205977089
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC CLINIC LLC

Provider Business Mailing Address
First Line	:	2401 VILLAGE PROFESSIONAL DRIVE
Second Line	:
City	:	OPELIKA
State	:	AL
Zip	:	36801-4702
Country	:	US
Telephone Number	:	334-749-8121
Fax Number	:	334-749-6166

Provider Business Practice Location Address
First Line	:	760 E GLENN AVE
Second Line	:
City	:	AUBURN
State	:	AL
Zip	:	36830-5017
Country	:	US
Telephone Number	:	334-749-8121
Fax Number	:	334-749-6166

Authorized Official
Title or Position	:	OFFICER
Name	:	DR. DAVID BRYANT SMALLEY
Credential	:	M.D.
Telephone Number	:	334-749-8121

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	08/22/2020

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