Healthcare Provider Details

I. General information

NPI: 1225229693
Provider Name (Legal Business Name): PEDIATRICS & GENETICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 05/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3586 OLD MILTON PKWY
ALPHARETTA GA
30005-4465
US

IV. Provider business mailing address

3180 N POINT PKWY SUITE 202
ALPHARETTA GA
30005-4248
US

V. Phone/Fax

Practice location:
  • Phone: 770-346-0132
  • Fax: 770-346-0165
Mailing address:
  • Phone: 770-346-0132
  • Fax: 770-346-0165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number05728
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number057528
License Number StateGA

VIII. Authorized Official

Name: VIDYA KRISHNAMURTHY
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 770-331-1660