Basic Information
| Provider Information | |||||||||
| NPI: | 1457539090 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIA HEALTHCARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5185 PEACHTREE PKWY | ||||||||
| Address2: | STE 350 | ||||||||
| City: | NORCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300926542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708401966 | ||||||||
| FaxNumber: | 7708401901 | ||||||||
| Practice Location | |||||||||
| Address1: | 1967 LAKESIDE PKWY | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | TUCKER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300845867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704140055 | ||||||||
| FaxNumber: | 7704140045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2008 | ||||||||
| LastUpdateDate: | 05/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | KILINSKI | ||||||||
| AuthorizedOfficialFirstName: | ROBBIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF BUSINESS OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7708401966 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PEDIATRIA HEALTHCARE, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM3000X | CCLC-18589 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Medically Fragile Intants and Children Day Care |
ID Information
| ID | Type | State | Issuer | Description | 656991060B | 05 | GA | MEDICAID |