Healthcare Provider Details

I. General information

NPI: 1770710824
Provider Name (Legal Business Name): CHILDREN'S MEDICINE OF ROCKDALE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 05/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1765 PARKER RD SE SUITE B210
CONYERS GA
30094-6652
US

IV. Provider business mailing address

1765 PARKER RD SUITE B210
CONYERS GA
30094
US

V. Phone/Fax

Practice location:
  • Phone: 770-761-0672
  • Fax:
Mailing address:
  • Phone: 770-761-0672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DAN EYSIE
Title or Position: OWNER
Credential:
Phone: 404-448-4652