Provider Demographics
NPI:1205205630
Name:JOURNEY PEDIATRICS
Entity Type:Organization
Organization Name:JOURNEY PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALWYN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-463-6618
Mailing Address - Street 1:12005 SAN ANTONIO DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-1096
Mailing Address - Country:US
Mailing Address - Phone:505-463-6618
Mailing Address - Fax:
Practice Address - Street 1:8308 CONSTITUTION PL NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-883-9570
Practice Address - Fax:505-883-4163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-16
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2003-0567261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM85684392Medicaid