Healthcare Provider Details

I. General information

NPI: 1669729257
Provider Name (Legal Business Name): MEADOW PEDIATRICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2012
Last Update Date: 08/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10710 MEDLOCK BRIDGE RD STE 250
JOHNS CREEK GA
30097-1827
US

IV. Provider business mailing address

10710 MEDLOCK BRIDGE RD STE 250
JOHNS CREEK GA
30097-1827
US

V. Phone/Fax

Practice location:
  • Phone: 310-707-8359
  • Fax: 770-825-9001
Mailing address:
  • Phone: 310-707-8359
  • Fax: 770-825-9001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number63377
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier558938842B
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: SRIDEVI MUTHUKUMAR
Title or Position: OWNER
Credential: MD
Phone: 310-707-8359