Provider Demographics
NPI:1689685315
Name:INFANTS AND CHILDRENS CLINIC PC
Entity Type:Organization
Organization Name:INFANTS AND CHILDRENS CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:COLVARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-764-9522
Mailing Address - Street 1:421 WEST COLLEGE ST
Mailing Address - Street 2:INFANTS AND CHILDRENS CLINIC PC
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630
Mailing Address - Country:US
Mailing Address - Phone:256-760-0670
Mailing Address - Fax:256-764-1139
Practice Address - Street 1:421 WEST COLLEGE ST
Practice Address - Street 2:INFANTS AND CHILDRENS CLINIC PC
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630
Practice Address - Country:US
Practice Address - Phone:256-760-0670
Practice Address - Fax:256-764-1139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL528601700Medicaid