MEDICARE: VITAL PEDIATRICS FOR COMPLEX KIDS LLC

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	2080H0002X	Pediatric Hospice and Palliative Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	80510	OTHER	GA	LICENSE

General Provider Information

NPI Number	:	1235726837
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITAL PEDIATRICS FOR COMPLEX KIDS LLC

Provider Business Mailing Address
First Line	:	1086 ARBOR TRCE NE
Second Line	:
City	:	BROOKHAVEN
State	:	GA
Zip	:	30319-5378
Country	:	US
Telephone Number	:	404-310-3252
Fax Number	:

Provider Business Practice Location Address
First Line	:	1086 ARBOR TRCE NE
Second Line	:
City	:	BROOKHAVEN
State	:	GA
Zip	:	30319-5378
Country	:	US
Telephone Number	:	404-310-3252
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PATRICIA SHEARER
Credential	:	MD
Telephone Number	:	404-310-3252

Provider Enumeration Date	:	12/29/2020
Last Update Date	:	12/29/2020

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