Healthcare Provider Details

I. General information

NPI: 1447075403
Provider Name (Legal Business Name): PEACH PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2024
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 OLD ATLANTA RD STE 500
CUMMING GA
30041-5867
US

IV. Provider business mailing address

3030 OLD ATLANTA RD STE 500
CUMMING GA
30041-5867
US

V. Phone/Fax

Practice location:
  • Phone: 770-203-2000
  • Fax: 770-886-7903
Mailing address:
  • Phone: 770-203-2000
  • Fax: 770-886-7903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MONAL SHAH
Title or Position: OWNER
Credential: MD
Phone: 404-944-5057