=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942326491
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARTERSVILLE PEDIATRIC ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2007
-----------------------------------------------------
Last Update Date | 12/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 958 JOE FRANK HARRIS PKWY SE SUITE 101
-----------------------------------------------------
City | CARTERSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30120-2174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-386-3011
-----------------------------------------------------
Fax | 770-386-9451
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 200429
-----------------------------------------------------
City | CARTERSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30120-9008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-386-3011
-----------------------------------------------------
Fax | 770-386-9451
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | WILLIAM R PAYNE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 770-386-3011
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------