Basic Information
| Provider Information | |||||||||
| NPI: | 1356922983 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC SERVICES OF AMERICA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 INTERSTATE NORTH PKWY SE STE 1600 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303395047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704411580 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12100 E ILIFF AVE STE A-250 | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800146316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033634107 | ||||||||
| FaxNumber: | 3033432182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2021 | ||||||||
| LastUpdateDate: | 04/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | WHITESIDE | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
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| AuthorizedOfficialTitleorPosition: | AVP REGULATORY LICENSING | ||||||||
| AuthorizedOfficialTelephone: | 7702488740 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253Z00000X | Y | Agencies | In Home Supportive Care |
No ID Information.