MEDICARE: PEDIATRIC SERVICES OF AMERICA, 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	251J00000X	Nursing Care Agency

General Provider Information

NPI Number	:	1285897025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC SERVICES OF AMERICA, LLC

Provider Business Mailing Address
First Line	:	400 INTERSTATE NORTH PKWY SE STE 1600
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30339-5047
Country	:	US
Telephone Number	:	770-441-1580
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 INTERSTATE NORTH PKWY SE STE 1600
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30339-5047
Country	:	US
Telephone Number	:	770-248-8740
Fax Number	:

Authorized Official
Title or Position	:	AVP, REGULATORY LICENSING
Name	:	VICKI WHITESIDE
Credential	:
Telephone Number	:	770-248-8740

Provider Enumeration Date	:	07/02/2008
Last Update Date	:	03/31/2021

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