Provider Demographics
NPI:1144315250
Name:SOUTHLAKE PEDIATRICS, INC.
Entity type:Organization
Organization Name:SOUTHLAKE PEDIATRICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:N
Authorized Official - Last Name:MCCOWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-982-2500
Mailing Address - Street 1:4515 SOUTHLAKE PARKWAY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BIRMINGHAM
Mailing Address - State:LA
Mailing Address - Zip Code:35244-3317
Mailing Address - Country:US
Mailing Address - Phone:205-982-2500
Mailing Address - Fax:205-982-2574
Practice Address - Street 1:4515 SOUTHLAKE PARKWAY
Practice Address - Street 2:SUITE 202
Practice Address - City:BIRMINGHAM
Practice Address - State:LA
Practice Address - Zip Code:35244-3317
Practice Address - Country:US
Practice Address - Phone:205-982-2500
Practice Address - Fax:205-982-2574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16701208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC76681Medicare UPIN
ALA03706Medicare UPIN
ALE45645Medicare UPIN