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General NPI Number Information
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NPI Number | 1790994317
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Entity Type | Organization
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Legal Business Name | PEDIATRIC ASSOCIATES, PC
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3000 JOHNSON FERRY RD SUITE 204
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City | MARIETTA
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State | GA
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Zip | 30062-5683
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Country | US
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Telephone | 770-993-2922
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Fax | 770-993-7325
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Provider Business Mailing Address
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Address Line | 3000 JOHNSON FERRY RD SUITE 204
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City | MARIETTA
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State | GA
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Zip | 30062-5683
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Country | US
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Telephone | 770-993-2922
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Fax | 770-993-7325
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ROBERT M. LICATA
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Credential | MD
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Telephone | 770-993-2922
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 025457
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License Number State | GA
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