Provider Demographics
NPI:1790844819
Name:SOUTHEAST PEDIATRICS
Entity Type:Organization
Organization Name:SOUTHEAST PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFIICER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOLLIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-724-0550
Mailing Address - Street 1:804 CRAWFORD ST
Mailing Address - Street 2:
Mailing Address - City:TUSKEGEE
Mailing Address - State:AL
Mailing Address - Zip Code:36083-7262
Mailing Address - Country:US
Mailing Address - Phone:334-724-0350
Mailing Address - Fax:
Practice Address - Street 1:804 CRAWFORD ST
Practice Address - Street 2:
Practice Address - City:TUSKEGEE
Practice Address - State:AL
Practice Address - Zip Code:36083-7262
Practice Address - Country:US
Practice Address - Phone:334-724-0350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0011822208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0011822OtherLICENSE NUMBER
AL5L502423OtherBLUECROSS
AL5L502423OtherBLUECROSS