Healthcare Provider Details

I. General information

NPI: 1467613232
Provider Name (Legal Business Name): PEDIATRIC CARDIOLOGY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 MILSTEAD AVE NE SUITE J
CONYERS GA
30012-3864
US

IV. Provider business mailing address

500 MEDICAL CENTER BLVD SUITE 340
LAWRENCEVILLE GA
30045
US

V. Phone/Fax

Practice location:
  • Phone: 770-995-6684
  • Fax: 770-995-7631
Mailing address:
  • Phone: 770-995-6684
  • Fax: 770-995-7631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number043298
License Number StateGA

VIII. Authorized Official

Name: MS. KIM WOODY
Title or Position: PRACTICE ADMINISTRATOR
Credential: RMM
Phone: 770-995-6684