Healthcare Provider Details

I. General information

NPI: 1083746838
Provider Name (Legal Business Name): PEDIATRICS AND ADOLESCENT MEDICINE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 08/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 POST OAK TRITT RD SUITE 100
MARIETTA GA
30062-8620
US

IV. Provider business mailing address

PO BOX 102613
ATLANTA GA
30368-2613
US

V. Phone/Fax

Practice location:
  • Phone: 770-973-4700
  • Fax: 770-973-5460
Mailing address:
  • Phone: 770-973-4700
  • Fax: 770-973-5460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22123
License Number StateGA

VIII. Authorized Official

Name: MRS. SUSAN SEVIN
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 770-973-4700