Healthcare Provider Details

I. General information

NPI: 1497820468
Provider Name (Legal Business Name): PEDIATRICARE PM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 12/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 W WHEELER PKWY
AUGUSTA GA
30909-1899
US

IV. Provider business mailing address

1215 W WHEELER PKWY
AUGUSTA GA
30909-1899
US

V. Phone/Fax

Practice location:
  • Phone: 706-868-1906
  • Fax: 706-868-0150
Mailing address:
  • Phone: 706-868-1906
  • Fax: 706-868-0150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: TERRI COOK
Title or Position: BUSINESS MANAGER
Credential:
Phone: 706-495-9627