Provider Demographics
NPI:1851515878
Name:SOUTH BALDWIN PEDIATRICS
Entity Type:Organization
Organization Name:SOUTH BALDWIN PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:EBERLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-943-7901
Mailing Address - Street 1:1090 EAST LAUREL AVENUE
Mailing Address - Street 2:
Mailing Address - City:FOLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36535-2248
Mailing Address - Country:US
Mailing Address - Phone:251-943-7901
Mailing Address - Fax:251-943-1949
Practice Address - Street 1:1090 EAST LAUREL AVENUE
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-2248
Practice Address - Country:US
Practice Address - Phone:251-943-7901
Practice Address - Fax:251-943-1949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21260208000000X
AL18394208000000X
AL1-050138363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL=========Medicaid