Provider Demographics
NPI:1316099203
Name:PEDIATRIC ASSOCIATES OF AUBURN
Entity type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF AUBURN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:MARTINEZ
Authorized Official - Last Name:CARLTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-203-1766
Mailing Address - Street 1:2901 CORPORATE PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-7283
Mailing Address - Country:US
Mailing Address - Phone:334-203-1766
Mailing Address - Fax:334-203-1784
Practice Address - Street 1:2901 CORPORATE PARK DR
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-7283
Practice Address - Country:US
Practice Address - Phone:334-203-1766
Practice Address - Fax:334-203-1784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL57382080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL528201420Medicaid
AL000044755Medicaid
AL51002165OtherBCBS RICHARD M. FREEMAN,
AL000002165Medicaid
AL51044755OtherBCBS ELLEN L. ROYAL, M.D.
ALG48986Medicare ID - Type UnspecifiedELLEN L. ROYAL, M.D.
AL51044755OtherBCBS ELLEN L. ROYAL, M.D.
AL000002165Medicaid
ALC76665Medicare ID - Type UnspecifiedRICHARD M. FREEMAN, M.D.