Provider Demographics
NPI:1104086800
Name:PROVIDENCE PEDIATRICS, LLC
Entity type:Organization
Organization Name:PROVIDENCE PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:FRANCIS-SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-939-7477
Mailing Address - Street 1:PO BOX 870527
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-0014
Mailing Address - Country:US
Mailing Address - Phone:770-939-7477
Mailing Address - Fax:770-939-7750
Practice Address - Street 1:2171 NORTHLAKE PKWY
Practice Address - Street 2:SUITE 114
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4104
Practice Address - Country:US
Practice Address - Phone:770-939-7477
Practice Address - Fax:770-939-7750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041796261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care