Provider Demographics
NPI:1811925308
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:AVP REGULATORY LICENSING
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITESIDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-248-8740
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:770-441-1580
Mailing Address - Fax:770-248-8192
Practice Address - Street 1:9105 NE HIGHWAY 99 STE 202
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-8974
Practice Address - Country:US
Practice Address - Phone:360-693-7595
Practice Address - Fax:360-693-7341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR152070251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500601760Medicaid
OR079967Medicaid