Healthcare Provider Details

I. General information

NPI: 1528469426
Provider Name (Legal Business Name): GWINNETT PEDIATRIC PARTNERS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2014
Last Update Date: 09/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 FIVE FORKS TRICKUM RD SW STE 102
LILBURN GA
30047-8975
US

IV. Provider business mailing address

PO BOX 4207
MACON GA
31208-4207
US

V. Phone/Fax

Practice location:
  • Phone: 770-923-6400
  • Fax: 770-564-1967
Mailing address:
  • Phone: 770-923-6400
  • Fax: 770-564-1697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: GEORGE KATSITADZE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 770-923-6400