Provider Demographics
NPI:1407361108
Name:WILLOW TREE PEDIATRICS PC
Entity Type:Organization
Organization Name:WILLOW TREE PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-708-6143
Mailing Address - Street 1:1641 EDGEWOOD ST NW
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35055-5739
Mailing Address - Country:US
Mailing Address - Phone:256-708-6143
Mailing Address - Fax:
Practice Address - Street 1:2108 AL HIGHWAY 157
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35058-0656
Practice Address - Country:US
Practice Address - Phone:256-735-4632
Practice Address - Fax:256-735-4639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19923208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL138096Medicaid