Healthcare Provider Details

I. General information

NPI: 1811495989
Provider Name (Legal Business Name): PEDIATRIC EPILEPSY AND CHILD (PEACH) NEUROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5935 THOROUGHBRED WAY
SUWANEE GA
30024-1744
US

IV. Provider business mailing address

5935 THOROUGHBRED WAY
SUWANEE GA
30024-1744
US

V. Phone/Fax

Practice location:
  • Phone: 847-691-7788
  • Fax:
Mailing address:
  • Phone: 847-691-7788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number72584
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number72584
License Number StateGA

VIII. Authorized Official

Name: DR. KOHILAVANI VELAYUDAM
Title or Position: DIRECTOR
Credential: MD
Phone: 847-691-7788