Provider Demographics
NPI:1194974907
Name:BRASELTON PEDIATRICS, PC
Entity type:Organization
Organization Name:BRASELTON PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARC-YRIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:BORIEUX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-787-8685
Mailing Address - Street 1:1651 TAILMORE LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7862
Mailing Address - Country:US
Mailing Address - Phone:678-820-7979
Mailing Address - Fax:
Practice Address - Street 1:1897 HIGHWAY 211 NW
Practice Address - Street 2:SUITE 100
Practice Address - City:HOSCHTON
Practice Address - State:GA
Practice Address - Zip Code:30548
Practice Address - Country:US
Practice Address - Phone:678-820-7979
Practice Address - Fax:678-820-7980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
059604OtherSTATE OF GEORGIA MEDICAL LICENSE
GA1700095742OtherNPI