MEDICARE: PEDIATRIC AND ADOLESCENT HEALTHCARE,PC

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	2080A0000X	Pediatric Adolescent Medicine Physician	037570	GA

General Provider Information

NPI Number	:	1922268838
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC AND ADOLESCENT HEALTHCARE,PC

Provider Business Mailing Address
First Line	:	1163 JOHNSON FERRY RD
Second Line	:	SUITE 170
City	:	MARIETTA
State	:	GA
Zip	:	30068-2764
Country	:	US
Telephone Number	:	770-971-5325
Fax Number	:

Provider Business Practice Location Address
First Line	:	1163 JOHNSON FERRY RD
Second Line	:	SUITE 170
City	:	MARIETTA
State	:	GA
Zip	:	30068-2764
Country	:	US
Telephone Number	:	770-971-5325
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. MONICA ELLEN HOLZWARTH
Credential	:	MD
Telephone Number	:	770-971-5325

Provider Enumeration Date	:	06/13/2008
Last Update Date	:	06/13/2008

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