=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184891400
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRICS AT WHITLOCK P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2008
-----------------------------------------------------
Last Update Date | 07/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 611 CAMPBELL HILL ST NW STE 103
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30060-1386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-499-8909
-----------------------------------------------------
Fax | 770-499-8911
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 611 CAMPBELL HILL ST NW STE 103
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30060-1386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-499-8909
-----------------------------------------------------
Fax | 770-499-8911
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MR. LAWRENCE VINCENT POOLD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-499-8909
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 047011
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------