Healthcare Provider Details

I. General information

NPI: 1922268838
Provider Name (Legal Business Name): PEDIATRIC AND ADOLESCENT HEALTHCARE,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1163 JOHNSON FERRY RD SUITE 170
MARIETTA GA
30068-2764
US

IV. Provider business mailing address

1163 JOHNSON FERRY RD SUITE 170
MARIETTA GA
30068-2764
US

V. Phone/Fax

Practice location:
  • Phone: 770-971-5325
  • Fax:
Mailing address:
  • Phone: 770-971-5325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number037570
License Number StateGA

VIII. Authorized Official

Name: DR. MONICA ELLEN HOLZWARTH
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 770-971-5325