Provider Demographics
NPI:1154605749
Name:DELTA PEDIATRICS,LLC
Entity type:Organization
Organization Name:DELTA PEDIATRICS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:MORDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-713-4646
Mailing Address - Street 1:3966 S BOGAN RD
Mailing Address - Street 2:BUILDING B
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-8633
Mailing Address - Country:US
Mailing Address - Phone:770-713-4646
Mailing Address - Fax:404-201-2923
Practice Address - Street 1:3966 S BOGAN RD
Practice Address - Street 2:BUILDING B
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-8633
Practice Address - Country:US
Practice Address - Phone:770-713-4646
Practice Address - Fax:404-201-2923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-01
Last Update Date:2011-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056894208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA112742695EMedicaid