Provider Demographics
NPI:1891766762
Name:PEDIATRIC SPECIALISTS OF MONTGOMERY, L.L.C.
Entity Type:Organization
Organization Name:PEDIATRIC SPECIALISTS OF MONTGOMERY, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MEREDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:DAFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-612-2111
Mailing Address - Street 1:239 MITYLENE PARK DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-3547
Mailing Address - Country:US
Mailing Address - Phone:334-612-2111
Mailing Address - Fax:334-612-2166
Practice Address - Street 1:239 MITYLENE PARK DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3547
Practice Address - Country:US
Practice Address - Phone:334-612-2111
Practice Address - Fax:334-612-2166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL166782080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALH12149Medicare UPIN
AL510-55256Medicare ID - Type Unspecified