Healthcare Provider Details

I. General information

NPI: 1487772596
Provider Name (Legal Business Name): ROSWELL PEDIATRIC CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11525 HAYNES BRIDGE RD STE 200
ALPHARETTA GA
30009-4822
US

IV. Provider business mailing address

11525 HAYNES BRIDGE RD STE 200
ALPHARETTA GA
30009-4822
US

V. Phone/Fax

Practice location:
  • Phone: 770-751-0800
  • Fax: 770-751-1401
Mailing address:
  • Phone: 770-751-0800
  • Fax: 770-751-1401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. LAURIE L VIEBROCK
Title or Position: PRACTICE ADMINISTRATOR
Credential: CMPE
Phone: 770-751-0800