Provider Demographics
NPI:1699908673
Name:PEDIATRIC ASSOCIATES OF DECATUR LLC
Entity type:Organization
Organization Name:PEDIATRIC ASSOCIATES OF DECATUR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSHIL
Authorized Official - Middle Name:S
Authorized Official - Last Name:VALAVALKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-306-9400
Mailing Address - Street 1:1874 BELTLINE RD SW
Mailing Address - Street 2:SUITE 160
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-5514
Mailing Address - Country:US
Mailing Address - Phone:256-306-9400
Mailing Address - Fax:256-306-9896
Practice Address - Street 1:1874 BELTLINE RD SW
Practice Address - Street 2:SUITE 160
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-5514
Practice Address - Country:US
Practice Address - Phone:256-306-9400
Practice Address - Fax:256-306-9896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-25
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD29718208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
I09385Medicare UPIN