Basic Information
| Provider Information | |||||||||
| NPI: | 1851444632 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC MEDICINE OF CARTERSVILLE, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 COLLINS DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CARTERSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301202486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706070795 | ||||||||
| FaxNumber: | 7706071339 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 COLLINS DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CARTERSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301202486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706070795 | ||||||||
| FaxNumber: | 7706071339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RYAN | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7706070795 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 042415 | GA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363LF0000X | RN120899 | GA | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0200X | RN089950 | GA | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.