Provider Demographics
NPI:1427252766
Name:MEDPEDS OF DOTHAN INC
Entity type:Organization
Organization Name:MEDPEDS OF DOTHAN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-671-2895
Mailing Address - Street 1:318 WESTGATE PARKWAY STE 2
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303
Mailing Address - Country:US
Mailing Address - Phone:334-671-2895
Mailing Address - Fax:334-712-9430
Practice Address - Street 1:318 WESTGATE PKWY STE 2
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-2963
Practice Address - Country:US
Practice Address - Phone:334-671-2895
Practice Address - Fax:334-712-9430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00024928207Q00000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009946055Medicaid
AL009946055Medicaid
ALH72415Medicare UPIN