Provider Demographics
NPI:1134286248
Name:PEDIATRIC CLINIC LLC
Entity Type:Organization
Organization Name:PEDIATRIC CLINIC LLC
Other - Org Name:PEDIATRIC CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BRYANT
Authorized Official - Last Name:SMALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-749-8121
Mailing Address - Street 1:2401 VILLAGE PROFESSIONAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-4702
Mailing Address - Country:US
Mailing Address - Phone:334-749-8121
Mailing Address - Fax:334-749-6166
Practice Address - Street 1:2401 VILLAGE PROFESSIONAL DRIVE
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-4702
Practice Address - Country:US
Practice Address - Phone:334-749-8121
Practice Address - Fax:334-749-6166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALD081Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER