Provider Demographics
NPI:1902975899
Name:PEDIATRIC ADOLESCENT MEDICINE, INC.
Entity type:Organization
Organization Name:PEDIATRIC ADOLESCENT MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KENDRICK-ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-874-4843
Mailing Address - Street 1:1107 VOEGLIN AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36703-4301
Mailing Address - Country:US
Mailing Address - Phone:334-874-4843
Mailing Address - Fax:334-874-9598
Practice Address - Street 1:1107 VOEGLIN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36703-4301
Practice Address - Country:US
Practice Address - Phone:334-874-4843
Practice Address - Fax:334-874-9598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL143142080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51500362OtherBCBS
ALD83870Medicare UPIN