# IMC-PEDIATRIC & ADOLESCENT MEDICINE, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1205905361
- **Authorized official:** ANTHONY PALAZZO (VICE PRESIDENT OF FINANCE)
- **Authorized official phone:** (251) 435-1361

## Contact information

- **Practice address:** 4013 AIRPORT BLVD STE C, MOBILE, AL 36608-2201
- **Practice address phone:** (251) 435-5437
- **Practice address fax:** (251) 435-6744
- **Mailing address:** 4013 AIRPORT BLVD STE C, MOBILE, AL 36608-2201
- **Mailing address phone:** (251) 435-5437
- **Mailing address fax:** (251) 435-6744

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2080A0000X | Pediatric Adolescent Medicine Physician | — | AL | Yes |

## Other

- **Enumeration date:** 11/06/2006
- **Last updated:** 06/26/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 51032409 | AL BCBS | AL |
| 01 | — | 51032411 | AL BCBS | AL |
| 01 | — | 51032412 | AL BCBS | AL |
| 01 | — | 51032413 | AL BCBS | AL |
| 05 | — | 529801010 | — | AL |