Healthcare Provider Details

I. General information

NPI: 1093729089
Provider Name (Legal Business Name): ABC PEDIATRIC GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 09/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 W PARK PLACE BLVD STE A
STONE MTN GA
30087-3543
US

IV. Provider business mailing address

2240 W PARK PLACE BLVD
STONE MTN GA
30087-3543
US

V. Phone/Fax

Practice location:
  • Phone: 770-771-5222
  • Fax: 770-771-5223
Mailing address:
  • Phone: 770-771-5222
  • Fax: 770-771-5223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARCIA A CUMBERBATCH
Title or Position: PARTNER
Credential: M.D.
Phone: 770-771-5222