Healthcare Provider Details

I. General information

NPI: 1134380017
Provider Name (Legal Business Name): PEDIATRIC EAR, NOSE, & THROAT OF ATLANTA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 05/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5461 MERIDIAN MARK ROAD SUITE 130
ATLANTA GA
30342
US

IV. Provider business mailing address

5461 MERIDIAN MARK ROAD SUITE 130
ATLANTA GA
30342-1654
US

V. Phone/Fax

Practice location:
  • Phone: 404-255-2033
  • Fax: 404-252-1901
Mailing address:
  • Phone: 404-255-2033
  • Fax: 404-252-1901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES R THOMSEN
Title or Position: PARTNER/PHYSICIAN
Credential: M.D.
Phone: 404-255-2033