Provider Demographics
NPI:1053405316
Name:MADISON VALLEY PEDIATRICS
Entity type:Organization
Organization Name:MADISON VALLEY PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:D
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-461-0209
Mailing Address - Street 1:3809 SULLIVAN ST
Mailing Address - Street 2:STE 5
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758
Mailing Address - Country:US
Mailing Address - Phone:256-461-0209
Mailing Address - Fax:256-772-1506
Practice Address - Street 1:3809 SULLIVAN ST
Practice Address - Street 2:STE 5
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758
Practice Address - Country:US
Practice Address - Phone:256-461-0209
Practice Address - Fax:256-772-1506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL20565208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1659348019OtherDRJACQUELINE C GALES NPI
AL51000822OtherBLUE CROSS
G60435Medicare UPIN