Provider Demographics
NPI:1770532681
Name:MONTGOMERY PEDIATRIC ASSOC, P.A.
Entity type:Organization
Organization Name:MONTGOMERY PEDIATRIC ASSOC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:OFFICE MANAGER
Authorized Official - Phone:334-260-9129
Mailing Address - Street 1:420 COTTON GIN RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-3557
Mailing Address - Country:US
Mailing Address - Phone:334-260-9129
Mailing Address - Fax:334-260-9665
Practice Address - Street 1:420 COTTON GIN RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3557
Practice Address - Country:US
Practice Address - Phone:334-260-9129
Practice Address - Fax:334-260-9665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL000062132080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL528301770Medicaid