Provider Demographics
NPI:1992742860
Name:PEDIATRIC RURAL HEALTH CLINICS, INC
Entity type:Organization
Organization Name:PEDIATRIC RURAL HEALTH CLINICS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:KEEN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:334-382-9760
Mailing Address - Street 1:46 L V STABLER DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36037-3804
Mailing Address - Country:US
Mailing Address - Phone:334-382-9760
Mailing Address - Fax:334-383-9331
Practice Address - Street 1:46 L V STABLER DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:AL
Practice Address - Zip Code:36037-3804
Practice Address - Country:US
Practice Address - Phone:334-382-9760
Practice Address - Fax:334-383-9331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00006213208000000X
AL00024891208000000X
AL00006634208000000X
AL1-065300363LP0200X
AL01-069655363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL541003905Medicaid
AL529800610Medicaid
AL541003905Medicaid