Provider Demographics
NPI:1467085902
Name:PEDIATRIC RHEUMATOLOGY ASSOCIATES LLC
Entity Type:Organization
Organization Name:PEDIATRIC RHEUMATOLOGY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KUETTEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-262-8645
Mailing Address - Street 1:29939 ONO BLVD
Mailing Address - Street 2:
Mailing Address - City:ORANGE BEACH
Mailing Address - State:AL
Mailing Address - Zip Code:36561-3634
Mailing Address - Country:US
Mailing Address - Phone:501-231-4367
Mailing Address - Fax:
Practice Address - Street 1:12591 SORRENTO RD STE A
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32507-8754
Practice Address - Country:US
Practice Address - Phone:850-262-8645
Practice Address - Fax:850-262-8647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-12
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No291U00000XLaboratoriesClinical Medical Laboratory
No332900000XSuppliersNon-Pharmacy Dispensing Site