Healthcare Provider Details

I. General information

NPI: 1366721706
Provider Name (Legal Business Name): PEDIATRIC ENDOCRINE SPECIALISTS OF GEORGIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2011
Last Update Date: 03/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10700 MEDLOCK BRIDGE RD SUITE 102
DULUTH GA
30097-8456
US

IV. Provider business mailing address

10700 MEDLOCK BRIDGE RD SUITE 102
DULUTH GA
30097-8456
US

V. Phone/Fax

Practice location:
  • Phone: 678-691-5351
  • Fax: 770-685-1241
Mailing address:
  • Phone: 678-691-5351
  • Fax: 770-685-1241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number60045
License Number StateGA

VIII. Authorized Official

Name: DR. PAUL JEROME BERNARD
Title or Position: PRESIDENT
Credential: MD
Phone: 314-374-1646