NPIMap

Organization Active NPI

Pediatric Associates of Alexander City PC

  • Pediatrics Physician
  • Kellyton, AL
National Provider Identifier
1952952541
Registry record updated Sep 25, 2019
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Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
PEDIATRIC ASSOCIATES OF ALEXANDER CITY PC
Practice address
21 Coosa County Road 50
Kellyton, AL 35089-1900
Phone
(256) 234-5021
NPI assigned
Sep 25, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 25, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Eric Owen TylerNPI 1881658706
Title
President
Phone
(256) 234-5021

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208000000X Primary
Rural Health Clinic/Center 261QR1300X

Addresses

Primary practice location

21 Coosa County Road 50
Kellyton, AL 35089-1900

Mailing address

PO Box 1269
Alexander City, AL 35011-1269
Phone (256) 234-5021

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20191122000988 AL Part A Provider - Rural Health Clinic 9638168891 Practice locations: Kellyton, AL

Rural health clinic certification: CCN 018946

Legal name
PEDIATRIC ASSOCIATES OF ALEXANDER CITY, P.C.
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 31, 2020
Last certification
Aug 13, 2020
Ownership / control type
1B
Organization structure
CorporationProprietary
Incorporated
May 9, 1985 in AL
Enrollment address
21 Coosa County Road 50
Kellyton, AL 35089-1900

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 1

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Eric Tyler Individual 5% Or Greater Direct Ownership Interest May 9, 1985 100%
Corporate OfficerPresident May 9, 1985 100%
W-2 Managing EmployeePresident May 9, 1985 100%
Operational/Managerial ControlPresident May 9, 1985 100%

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1569369600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1569369600000",
    "number": "1952952541",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1269",
            "city": "ALEXANDER CITY",
            "state": "AL",
            "postal_code": "350111269",
            "telephone_number": "256-234-5021",
            "fax_number": "256-234-5640"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "21 COOSA COUNTY ROAD 50",
            "city": "KELLYTON",
            "state": "AL",
            "postal_code": "350891900",
            "telephone_number": "256-234-5021"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEDIATRIC ASSOCIATES OF ALEXANDER CITY PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-09-25",
        "last_updated": "2019-09-25",
        "status": "A",
        "authorized_official_last_name": "TYLER",
        "authorized_official_first_name": "ERIC",
        "authorized_official_middle_name": "OWEN",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "256-234-5021"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Kellyton, AL

Sources for this page

Verify at the official NPI Registry.