Basic Information
| Provider Information | |||||||||
| NPI: | 1922276252 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YOUTHCARE PEDIATRICS OF CENTRAL GEORGIA, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 233 N HOUSTON RD | ||||||||
| Address2: | STE 140 H | ||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310933074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789233360 | ||||||||
| FaxNumber: | 4789239977 | ||||||||
| Practice Location | |||||||||
| Address1: | 233 N HOUSTON RD | ||||||||
| Address2: | SUITE 140-H | ||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310933074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789233360 | ||||||||
| FaxNumber: | 4789239977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2008 | ||||||||
| LastUpdateDate: | 04/13/2009 | ||||||||
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| AuthorizedOfficialLastName: | WADE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | STEPHEN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4789233360 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000377836D | 05 | GA | MEDICAID |