Provider Demographics
NPI:1033477393
Name:FORT PAYNE PEDIATRICS LLC
Entity Type:Organization
Organization Name:FORT PAYNE PEDIATRICS LLC
Other - Org Name:FT PAYNE PEDIATRICS,LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:STROGOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-997-5900
Mailing Address - Street 1:1906 GLENN BLVD SW STE 100A
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35968-3546
Mailing Address - Country:US
Mailing Address - Phone:256-997-5900
Mailing Address - Fax:
Practice Address - Street 1:1906 GLENN BLVD SW STE 100A
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35968-3546
Practice Address - Country:US
Practice Address - Phone:256-997-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL30426208000000X
AL01-8910261QR1300X
AL1-075895363LF0000X
AL1-087445363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL139385Medicaid