1154810224 NPI number — KIDS CLINIC PEDIATRIC AND ADOLESCENT MEDICINE

Table of content: (NPI 1154810224)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154810224 NPI number — KIDS CLINIC PEDIATRIC AND ADOLESCENT MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDS CLINIC PEDIATRIC AND ADOLESCENT MEDICINE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154810224
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
119 STEPHEN J WHITE MEMORIAL BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TALLADEGA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35160-2106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-268-7775
Provider Business Mailing Address Fax Number:
256-268-7760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 STEPHEN J WHITE MEMORIAL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TALLADEGA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35160-2106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-268-7775
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/04/2018

Additional Information

Authorized Official

Authorized Official Last Name:
SIDDIQUI
Authorized Official First Name:
MUHAMMED
Authorized Official Middle Name:
KHURRAM
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
256-268-7775

Provider Taxonomy Codes

  • Taxonomy code: 2080A0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000032739 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: G50661 . This is a "UPIN" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com