Provider Demographics
NPI:1902020639
Name:AMORY PEDIATRIC
Entity Type:Organization
Organization Name:AMORY PEDIATRIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DEDEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-256-7112
Mailing Address - Street 1:123 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-3416
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1107 EARL FRYE BLVD STE 5
Practice Address - Street 2:
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-5519
Practice Address - Country:US
Practice Address - Phone:662-257-6705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty