Provider Demographics
NPI:1932121845
Name:GULF SHORES PEDIATRICS PC
Entity Type:Organization
Organization Name:GULF SHORES PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:LAVLIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-968-2323
Mailing Address - Street 1:232 OFFICE PARK DR.
Mailing Address - Street 2:
Mailing Address - City:GULF SHORES
Mailing Address - State:AL
Mailing Address - Zip Code:36542
Mailing Address - Country:US
Mailing Address - Phone:251-968-2323
Mailing Address - Fax:251-968-2624
Practice Address - Street 1:232 OFFICE PARK DR.
Practice Address - Street 2:
Practice Address - City:GULF SHORES
Practice Address - State:AL
Practice Address - Zip Code:36542
Practice Address - Country:US
Practice Address - Phone:251-968-2323
Practice Address - Fax:251-968-2624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22320208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL39807OtherBCBS