Provider Demographics
NPI:1447668199
Name:PRINCE EDWARD PEDIATRICS
Entity type:Organization
Organization Name:PRINCE EDWARD PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:IBTEHAL
Authorized Official - Middle Name:
Authorized Official - Last Name:AL-ANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-315-0138
Mailing Address - Street 1:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:RICE
Mailing Address - State:VA
Mailing Address - Zip Code:23966-0097
Mailing Address - Country:US
Mailing Address - Phone:434-315-0138
Mailing Address - Fax:434-392-9748
Practice Address - Street 1:1715 W 3RD ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-2651
Practice Address - Country:US
Practice Address - Phone:434-315-0138
Practice Address - Fax:434-392-9748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-25
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101242689208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1609040658Medicaid