Provider Demographics
NPI:1326226986
Name:PEDIATRIA HEALTHCARE, LLC
Entity type:Organization
Organization Name:PEDIATRIA HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF BUSINESS OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:K
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-840-1966
Mailing Address - Street 1:5185 PEACHTREE PKWY
Mailing Address - Street 2:SUITE 350
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-6542
Mailing Address - Country:US
Mailing Address - Phone:770-840-1966
Mailing Address - Fax:770-840-1901
Practice Address - Street 1:2407 WESTGATE DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-2225
Practice Address - Country:US
Practice Address - Phone:229-434-8101
Practice Address - Fax:229-434-8104
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIA HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-06
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA191825955AMedicaid