Provider Demographics
NPI:1104240324
Name:MOBILE PEDIATRIC CLINIC LLC
Entity type:Organization
Organization Name:MOBILE PEDIATRIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-610-1618
Mailing Address - Street 1:PO BOX 91899
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36691-1899
Mailing Address - Country:US
Mailing Address - Phone:251-706-8170
Mailing Address - Fax:251-706-8098
Practice Address - Street 1:6321 PICCADILLY SQUARE DR STE A
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-5305
Practice Address - Country:US
Practice Address - Phone:251-342-8900
Practice Address - Fax:251-342-2333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-07
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL156442Medicaid