Healthcare Provider Details

I. General information

NPI: 1487782942
Provider Name (Legal Business Name): PEACHTREE PEDIATRICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 09/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 MEDICAL PARK LN SUITE F
MURPHY NC
28906-6920
US

IV. Provider business mailing address

125 MEDICAL PARK LN SUITE F
MURPHY NC
28906-6920
US

V. Phone/Fax

Practice location:
  • Phone: 828-837-2128
  • Fax: 828-837-6244
Mailing address:
  • Phone: 828-837-2128
  • Fax: 828-837-6244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier89012C7
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: KATHRYN GIBSON WAGGONER
Title or Position: OWNER
Credential: D.O.
Phone: 828-837-2128