MEDICARE: GWINNETT PEDIATRIC PARTNERS, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1528469426
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GWINNETT PEDIATRIC PARTNERS, INC

Provider Business Mailing Address
First Line	:	PO BOX 4207
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31208-4207
Country	:	US
Telephone Number	:	770-923-6400
Fax Number	:	770-564-1697

Provider Business Practice Location Address
First Line	:	4120 FIVE FORKS TRICKUM RD SW
Second Line	:	STE 102
City	:	LILBURN
State	:	GA
Zip	:	30047-8975
Country	:	US
Telephone Number	:	770-923-6400
Fax Number	:	770-564-1967

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GEORGE KATSITADZE
Credential	:	M.D.
Telephone Number	:	770-923-6400

Provider Enumeration Date	:	09/10/2014
Last Update Date	:	09/15/2014

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