Basic Information
| Provider Information | |||||||||
| NPI: | 1902390206 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERALTA | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | MCGUINNESS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2876 | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317762876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298919131 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | COLQUITT REGIONAL MEDICAL CENTER | ||||||||
| Address2: | 3131 S MAIN ST | ||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2295029782 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2018 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35146660 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | 35146660 | OH | N | Allopathic & Osteopathic Physicians | Hospitalist | 208000000X | 010083 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 010083 | 01 | GA | AUGUSTA UNIVERSITY GRADUATE MEDICAL EDUCATION | OTHER |