MEDICARE: DR. ROMUALDA S KLICIUS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	046305	GA

General Provider Information

NPI Number	:	1033108121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROMUALDA S KLICIUS MD

Provider Business Mailing Address
First Line	:	2230 TOWNE LAKE PKWY
Second Line	:	BUILDING 300, SUITE 100
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-5540
Country	:	US
Telephone Number	:	770-517-1900
Fax Number	:	770-926-3215

Provider Business Practice Location Address
First Line	:	2230 TOWNE LAKE PKWY
Second Line	:	BUILDING 300, SUITE 100
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-5540
Country	:	US
Telephone Number	:	770-517-1900
Fax Number	:	770-926-3215

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	12/12/2011

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