Provider Demographics
NPI:1154956621
Name:GEORGIA CENTER FOR AUTISM AND DEVELOPMENTAL PEDIATRICS, LLC
Entity type:Organization
Organization Name:GEORGIA CENTER FOR AUTISM AND DEVELOPMENTAL PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:MONCINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-748-6013
Mailing Address - Street 1:6065 ROSWELL RD STE 470
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4067
Mailing Address - Country:US
Mailing Address - Phone:404-748-6013
Mailing Address - Fax:866-984-3407
Practice Address - Street 1:6065 ROSWELL RD STE 470
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-4067
Practice Address - Country:US
Practice Address - Phone:770-824-3395
Practice Address - Fax:770-691-5116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-05
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Single Specialty