Healthcare Provider Details

I. General information

NPI: 1932389608
Provider Name (Legal Business Name): PEDIATRIC ENDOCRINE ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LAKE HEARN DR NE SUITE 350
ATLANTA GA
30342-1523
US

IV. Provider business mailing address

1100 LAKE HEARN DR NE SUITE 350
ATLANTA GA
30342-1523
US

V. Phone/Fax

Practice location:
  • Phone: 404-255-0015
  • Fax: 404-845-3080
Mailing address:
  • Phone: 404-255-0015
  • Fax: 404-845-3080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number25935
License Number StateGA

VIII. Authorized Official

Name: MR. MARK A. SPANGLER
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 404-255-1267