Provider Demographics
NPI:1831151331
Name:EASTERN SHORE CHILDREN'S CLINIC
Entity type:Organization
Organization Name:EASTERN SHORE CHILDREN'S CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:ELLIOT
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-928-0624
Mailing Address - Street 1:PO BOX 989
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36533-0989
Mailing Address - Country:US
Mailing Address - Phone:251-928-0624
Mailing Address - Fax:251-928-0655
Practice Address - Street 1:150 S INGLESIDE ST
Practice Address - Street 2:SUITE 7
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-1803
Practice Address - Country:US
Practice Address - Phone:251-928-0624
Practice Address - Fax:251-928-0655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000810930Medicaid