Provider Demographics
NPI:1871844134
Name:SOUTHEAST PEDIATRICS,P.C.
Entity Type:Organization
Organization Name:SOUTHEAST PEDIATRICS,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
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:334-724-0550
Mailing Address - Fax:334-724-0591
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:334-724-0550
Practice Address - Fax:334-724-0591
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST PEDIATRICS,P.C
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11822261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529933919Medicaid