Healthcare Provider Details

I. General information

NPI: 1609247311
Provider Name (Legal Business Name): TRINITY PEDIATRIC MEDICINE OF FAYETTEVILLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2015
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3695 CASCADE RD SW STE V
ATLANTA GA
30331-2146
US

IV. Provider business mailing address

719 LANIER AVE W STE A2
FAYETTEVILLE GA
30214-7634
US

V. Phone/Fax

Practice location:
  • Phone: 404-696-6595
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. PAUL MCKOY
Title or Position: CFO
Credential:
Phone: 678-517-8368