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General NPI Number Information
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NPI Number | 1891065504
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Entity Type | Organization
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Legal Business Name | CAMP CREEK PEDIATRICS
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Dates
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Enumeration Date | 01/11/2012
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Last Update Date | 01/11/2012
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Provider Practice Location Address
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Address Line | 495 VIRGINIA HIGHLANDS
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City | FAYETTEVILLE
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State | GA
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Zip | 30215-8233
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Country | US
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Telephone | 770-460-6459
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Fax |
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Provider Business Mailing Address
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Address Line | 2945 STONE HOGAN CONNECTOR RD SW STE 201
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City | ATLANTA
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State | GA
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Zip | 30331-2839
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Country | US
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Telephone | 404-349-6758
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Fax | 404-349-6759
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | KATHY ANN DYSON
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Credential |
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Telephone | 770-745-1070
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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 | 049655
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License Number State | GA
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