Provider Demographics
NPI:1104159086
Name:WOODSTOCK PEDIATRICS PC
Entity type:Organization
Organization Name:WOODSTOCK PEDIATRICS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:T
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-632-0330
Mailing Address - Street 1:460 W MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-7127
Mailing Address - Country:US
Mailing Address - Phone:706-632-0330
Mailing Address - Fax:706-632-9004
Practice Address - Street 1:460 W MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-7127
Practice Address - Country:US
Practice Address - Phone:706-632-0330
Practice Address - Fax:706-632-9004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-10
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032063208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000448269FMedicaid
GAH72549Medicare UPIN
GA000448269FMedicaid