Provider Demographics
NPI:1043242514
Name:MARSHALL COUNTY PEDIATRICS, PC
Entity type:Organization
Organization Name:MARSHALL COUNTY PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MALLORY
Authorized Official - Last Name:PACKARD
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:256-571-8969
Mailing Address - Street 1:45 MEDICAL PARK DR STE B
Mailing Address - Street 2:
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976-6999
Mailing Address - Country:US
Mailing Address - Phone:256-571-8969
Mailing Address - Fax:256-571-8980
Practice Address - Street 1:45 MEDICAL PARK DR STE B
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-6999
Practice Address - Country:US
Practice Address - Phone:256-571-8969
Practice Address - Fax:256-571-8980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6719174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALH66960Medicare UPIN
ALH54634Medicare UPIN
AL#82775Medicare UPIN
ALC76801Medicare UPIN
ALG10242Medicare UPIN