Healthcare Provider Details

I. General information

NPI: 1619155751
Provider Name (Legal Business Name): PEDIATRIC CARE AFTER HOURS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 04/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 S HOUSTON RD
WARNER ROBINS GA
31088-3904
US

IV. Provider business mailing address

116 S HOUSTON RD
WARNER ROBINS GA
31088-3904
US

V. Phone/Fax

Practice location:
  • Phone: 478-923-0131
  • Fax: 478-922-6530
Mailing address:
  • Phone: 478-923-0131
  • Fax: 478-922-6530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number032131
License Number StateGA

VIII. Authorized Official

Name: KIMBERLY T. BLEVENS
Title or Position: PHYSICIAN
Credential: MD
Phone: 478-923-0131