Provider Demographics
NPI:1245256494
Name:HEALTHYKIDS OF GARDENDALE
Entity type:Organization
Organization Name:HEALTHYKIDS OF GARDENDALE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-608-2055
Mailing Address - Street 1:1127 PECAN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GARDENDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35071-2543
Mailing Address - Country:US
Mailing Address - Phone:205-608-2055
Mailing Address - Fax:205-608-2045
Practice Address - Street 1:1127 PECAN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:GARDENDALE
Practice Address - State:AL
Practice Address - Zip Code:35071-2543
Practice Address - Country:US
Practice Address - Phone:205-608-2055
Practice Address - Fax:205-608-2045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00023211305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALI04447Medicare UPIN