MEDICARE: PEDIATRIC ADOLESCENT MEDICINE, INC.

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	2080A0000X	Pediatric Adolescent Medicine Physician	14314	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	51500362	OTHER	AL	BCBS

General Provider Information

NPI Number	:	1902975899
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC ADOLESCENT MEDICINE, INC.

Provider Business Mailing Address
First Line	:	1107 VOEGLIN AVE
Second Line	:	SUITE 202
City	:	SELMA
State	:	AL
Zip	:	36703-4301
Country	:	US
Telephone Number	:	334-874-4843
Fax Number	:	334-874-9598

Provider Business Practice Location Address
First Line	:	1107 VOEGLIN AVE
Second Line	:	SUITE 202
City	:	SELMA
State	:	AL
Zip	:	36703-4301
Country	:	US
Telephone Number	:	334-874-4843
Fax Number	:	334-874-9598

Authorized Official
Title or Position	:	M.D.
Name	:	MRS. PATRICIA ANN KENDRICK-ROBINSON
Credential	:
Telephone Number	:	334-874-4843

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	08/22/2020

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