MEDICARE: NUESTROS NINOS OUR KIDS PEDIATRICS PC

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	363LP0200X	Pediatric Nurse Practitioner	RN083997	GA
2	363LF0000X	Family Nurse Practitioner	RN170709	GA

General Provider Information

NPI Number	:	1205819737
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NUESTROS NINOS OUR KIDS PEDIATRICS PC

Provider Business Mailing Address
First Line	:	393 MAXHAM RD
Second Line	:	SUITES A&B
City	:	AUSTELL
State	:	GA
Zip	:	30168-5539
Country	:	US
Telephone Number	:	770-732-6007
Fax Number	:	770-732-8242

Provider Business Practice Location Address
First Line	:	393 MAXHAM RD
Second Line	:	SUITES A&B
City	:	AUSTELL
State	:	GA
Zip	:	30168-5539
Country	:	US
Telephone Number	:	770-732-6007
Fax Number	:	770-732-8242

Authorized Official
Title or Position	:	OWNERCEO
Name	:	MARY ELIZABETH CAHILL
Credential	:	CPNP
Telephone Number	:	770-732-6007

Provider Enumeration Date	:	11/29/2005
Last Update Date	:	09/11/2025

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