=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114064540
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN LEE DELLI-GATTI MD FAAP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 403 W GORDON ST
-----------------------------------------------------
City | THOMASTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-647-1680
-----------------------------------------------------
Fax | 706-646-3125
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 403 W GORDON ST
-----------------------------------------------------
City | THOMASTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-647-1680
-----------------------------------------------------
Fax | 706-646-3125
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 027529
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------