Healthcare Provider Details

I. General information

NPI: 1689884694
Provider Name (Legal Business Name): PEDIATRIC ASSOCIATES OF THOMASTON, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 09/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 W MAIN ST
THOMASTON GA
30286-3502
US

IV. Provider business mailing address

331 W MAIN ST
THOMASTON GA
30286-3502
US

V. Phone/Fax

Practice location:
  • Phone: 706-646-4543
  • Fax: 706-938-0401
Mailing address:
  • Phone: 706-646-4543
  • Fax: 706-938-0401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. KATHY E MANSFIELD
Title or Position: CEO
Credential: MD
Phone: 706-646-4543