Healthcare Provider Details

I. General information

NPI: 1639206030
Provider Name (Legal Business Name): PEDIATRIC PLASTIC SURGERY AND CRANIOFACIAL ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 JOHNSON FERRY RD NE SUITE 500
ATLANTA GA
30342-1619
US

IV. Provider business mailing address

975 JOHNSON FERRY RD NE SUITE 500
ATLANTA GA
30342-1619
US

V. Phone/Fax

Practice location:
  • Phone: 404-256-1311
  • Fax: 404-705-2772
Mailing address:
  • Phone: 404-256-1311
  • Fax: 404-705-2772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number StateGA

VIII. Authorized Official

Name: ANDY GUTH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 404-256-1311