Provider Demographics
NPI:1851444632
Name:PEDIATRIC MEDICINE OF CARTERSVILLE, P.C.
Entity type:Organization
Organization Name:PEDIATRIC MEDICINE OF CARTERSVILLE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-607-0795
Mailing Address - Street 1:20 COLLINS DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-2486
Mailing Address - Country:US
Mailing Address - Phone:770-607-0795
Mailing Address - Fax:770-607-1339
Practice Address - Street 1:20 COLLINS DR
Practice Address - Street 2:SUITE B
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2486
Practice Address - Country:US
Practice Address - Phone:770-607-0795
Practice Address - Fax:770-607-1339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042415208000000X
GARN120899363LF0000X
GARN089950363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Not Answered363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTIN