Provider Demographics
NPI:1568633071
Name:PEDIATRIA HEALTHCARE, LLC
Entity type:Organization
Organization Name:PEDIATRIA HEALTHCARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKHALTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-464-8000
Mailing Address - Street 1:400 INTERSTATE NORTH PKWY SE STE 1600
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-5047
Mailing Address - Country:US
Mailing Address - Phone:470-464-8000
Mailing Address - Fax:
Practice Address - Street 1:2420 DOUBLE CHURCHES RD STE B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-2984
Practice Address - Country:US
Practice Address - Phone:706-322-3693
Practice Address - Fax:706-322-8443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106-R-0416251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA804642159AMedicaid