Provider Demographics
NPI:1215093430
Name:CHILD AND ADOLESCENT MEDICAL PROVIDERS, P.C.
Entity type:Organization
Organization Name:CHILD AND ADOLESCENT MEDICAL PROVIDERS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-356-5439
Mailing Address - Street 1:13375 JONES ST STE C
Mailing Address - Street 2:
Mailing Address - City:LAVONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30553-1147
Mailing Address - Country:US
Mailing Address - Phone:706-356-5439
Mailing Address - Fax:706-356-5897
Practice Address - Street 1:13375 JONES ST STE C
Practice Address - Street 2:
Practice Address - City:LAVONIA
Practice Address - State:GA
Practice Address - Zip Code:30553-1147
Practice Address - Country:US
Practice Address - Phone:706-356-5439
Practice Address - Fax:706-356-5897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047486208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA309143Medicaid
GA52768660OtherBCBS PIN#
GA85002622GMedicaid
GA00860219CMedicaid
GA10056443Medicaid
GA85002622GMedicaid