Healthcare Provider Details

I. General information

NPI: 1255586004
Provider Name (Legal Business Name): PEDIATRIC EMERGENCY MEDICINE ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2008
Last Update Date: 11/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 HIGHWAY 54 W
FAYETTEVILLE GA
30214-4526
US

IV. Provider business mailing address

PO BOX 422002
ATLANTA GA
30342-9002
US

V. Phone/Fax

Practice location:
  • Phone: 678-344-1960
  • Fax: 678-344-1960
Mailing address:
  • Phone: 678-344-1960
  • Fax: 678-344-1960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID A WERNER
Title or Position: CHIEF FINANCIAL OFFICER
Credential: MD
Phone: 678-344-1960