Healthcare Provider Details

I. General information

NPI: 1437397809
Provider Name (Legal Business Name): ATHENS PEDIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2009
Last Update Date: 01/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 EPPERSON ST
ATHENS TN
37303-3478
US

IV. Provider business mailing address

111 EPPERSON ST
ATHENS TN
37303-3478
US

V. Phone/Fax

Practice location:
  • Phone: 423-745-5955
  • Fax: 423-745-6423
Mailing address:
  • Phone: 423-745-5955
  • Fax: 423-745-6423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD32738
License Number StateTN

VIII. Authorized Official

Name: CINDY ACKAOUY
Title or Position: OFFICE MANAGER
Credential:
Phone: 423-745-5955