| Name: | Willow Tree Pediatrics, P.C. |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Professional Corporation |
| Status: | Exists |
| Date of registration: | 22 Nov 2017 (7 years ago) |
| Entity Number: | 000-408-681 |
| Register Number: | 000408681 |
| County: | Cullman |
| Place of Formation: | Cullman County |
| Registered Office Street Address: | 409 SECOND AVENUE NORTHWESTCULLMAN, AL 35055 |
| Registered Office Street Address ZIP Code: | 35055 |
| Authorized Capital: | 1000 @ $0.01 PV |
Activities
MEDICAL/HEALTH RELATED SEVICES/OTHER SERVICES ANCILLARY THERETO
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1407361108 | 2017-12-05 | 2018-03-17 | 1641 EDGEWOOD ST NW, CULLMAN, AL, 350555739, US | 2108 AL HIGHWAY 157, CULLMAN, AL, 350580656, US | |||||||||||||||||||||||||||
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| Phone | +1 256-708-6143 |
| Phone | +1 256-735-4632 |
| Fax | 2567354639 |
Authorized person
| Name | DR. HEIDI BLAIR |
| Role | PROVIDER/OWNER |
| Phone | 2567086143 |
Taxonomy
| Taxonomy Code | 208000000X - Pediatrics Physician |
| License Number | 19923 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 138096 |
| State | AL |
| Name | Role | Address |
|---|---|---|
| BLAIR, HEIDI H | Agent | 1641 EDGEWOOD ST NORTHWESTCULLMAN, AL 35055 |
| Name | Role | Address |
|---|---|---|
| BLAIR, HEIDI H | Director | 1641 EDGEWOOD ST NORTHWESTCULLMAN, AL 35055 |
| Name | Role | Address |
|---|---|---|
| BLAIR, HEIDI H | Incorporator | 1641 EDGEWOOD ST NORTHWESTCULLMAN, AL 35055 |
Date of last update: 13 Aug 2024
Sources: Alabama Secretary of State
