Healthcare Provider Details

I. General information

NPI: 1104159086
Provider Name (Legal Business Name): WOODSTOCK PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2009
Last Update Date: 01/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 W MAIN ST SUITE 100
BLUE RIDGE GA
30513-7127
US

IV. Provider business mailing address

460 W MAIN ST SUITE 100
BLUE RIDGE GA
30513-7127
US

V. Phone/Fax

Practice location:
  • Phone: 706-632-0330
  • Fax: 706-632-9004
Mailing address:
  • Phone: 706-632-0330
  • Fax: 706-632-9004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number032063
License Number StateGA

VIII. Authorized Official

Name: DR. KIMBERLY T WILLIAMS
Title or Position: M.D.
Credential: M.D.
Phone: 706-632-0330