Provider Demographics
NPI:1699707968
Name:PEDIATRIC SERVICES OF AMERICA, LLC
Entity type:Organization
Organization Name:PEDIATRIC SERVICES OF AMERICA, 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:770-248-8192
Practice Address - Street 1:9105 NE HIGHWAY 99
Practice Address - Street 2:STE 202, BUILDING A
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-8961
Practice Address - Country:US
Practice Address - Phone:360-639-7595
Practice Address - Fax:360-693-7262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
WAIS-423251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9046731Medicaid
WA9049651Medicaid
WA50-7095Medicare Oscar/Certification