Healthcare Provider Details

I. General information

NPI: 1447383351
Provider Name (Legal Business Name): KIDS TIME PEDIATRICS OF SOUTHERN CRESCENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 SUMNER RD SUITE D
FAYETTEVILLE GA
30214-4758
US

IV. Provider business mailing address

696 BILLUPS AVE
MADISON GA
30650-1439
US

V. Phone/Fax

Practice location:
  • Phone: 706-342-2180
  • Fax:
Mailing address:
  • Phone: 706-342-2180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: FLYNN CLYBURN
Title or Position: PRESIDENT
Credential:
Phone: 706-342-2180