Provider Demographics
NPI:1457364994
Name:ANNISTON PEDIATRICS, INC
Entity Type:Organization
Organization Name:ANNISTON PEDIATRICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-237-1618
Mailing Address - Street 1:1001 LEIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36207-5782
Mailing Address - Country:US
Mailing Address - Phone:256-237-1618
Mailing Address - Fax:256-237-2661
Practice Address - Street 1:1001 LEIGHTON AVE
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-5782
Practice Address - Country:US
Practice Address - Phone:256-237-1618
Practice Address - Fax:256-237-2661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00015180208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALF942OtherBLUE CROSS BLUE SHIELD
AL891009700Medicaid
AL1210952OtherUNITED HEALTH CARE
AL1210953OtherUNITED HEALTH CARE
AL891009710Medicaid
AL009931864Medicaid
AL009931866Medicaid
AL009931864Medicaid
AL009931866Medicaid
ALG55083Medicare UPIN
AL009931866Medicaid
AL891009710Medicaid