Provider Demographics
NPI:1972529808
Name:ETOWAH PEDIATRICS
Entity Type:Organization
Organization Name:ETOWAH PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HESTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-413-1467
Mailing Address - Street 1:170 INDEPENDENT DR
Mailing Address - Street 2:
Mailing Address - City:RAINBOW CITY
Mailing Address - State:AL
Mailing Address - Zip Code:35906-3286
Mailing Address - Country:US
Mailing Address - Phone:256-413-1467
Mailing Address - Fax:256-413-1470
Practice Address - Street 1:170 INDEPENDENT DR
Practice Address - Street 2:
Practice Address - City:RAINBOW CITY
Practice Address - State:AL
Practice Address - Zip Code:35906-3286
Practice Address - Country:US
Practice Address - Phone:256-413-1467
Practice Address - Fax:256-413-1470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL23664208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529926830Medicaid
AL529926830Medicaid