Provider Demographics
NPI:1982993283
Name:PEDIAKARE OF NEWNAN, INC
Entity type:Organization
Organization Name:PEDIAKARE OF NEWNAN, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:B
Authorized Official - Last Name:DARRAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-243-4500
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31908-9007
Mailing Address - Country:US
Mailing Address - Phone:706-615-4736
Mailing Address - Fax:706-221-6226
Practice Address - Street 1:1111 BULLSBORO DR
Practice Address - Street 2:SUITE 6 AND 7
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2182
Practice Address - Country:US
Practice Address - Phone:706-615-4736
Practice Address - Fax:706-221-6226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA065633208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR440194601Medicaid