Provider Demographics
NPI:1427333095
Name:DAHLONEGA PEDIATRIC AND ADOLESCENT MEDICINE
Entity type:Organization
Organization Name:DAHLONEGA PEDIATRIC AND ADOLESCENT MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-864-6700
Mailing Address - Street 1:1055 NORTH GROVE ST
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533
Mailing Address - Country:US
Mailing Address - Phone:706-864-6700
Mailing Address - Fax:706-864-2599
Practice Address - Street 1:1055 NORTH GROVE ST.
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533
Practice Address - Country:US
Practice Address - Phone:706-864-6700
Practice Address - Fax:706-864-2599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-14
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN0681352080A0000X
GA11-8910261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000548369CMedicaid