Basic Information
| Provider Information | |||||||||
| NPI: | 1134380017 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC EAR, NOSE, & THROAT OF ATLANTA, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5461 MERIDIAN MARK ROAD SUITE 130 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042552033 | ||||||||
| FaxNumber: | 4042521901 | ||||||||
| Practice Location | |||||||||
| Address1: | 5461 MERIDIAN MARK ROAD SUITE 130 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042552033 | ||||||||
| FaxNumber: | 4042521901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2008 | ||||||||
| LastUpdateDate: | 05/25/2018 | ||||||||
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| AuthorizedOfficialLastName: | THOMSEN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4042552033 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YP0228X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology |
No ID Information.