MEDICARE: KIDCARE PEDIATRICS

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	302R00000X	Health Maintenance Organization	057447	GA
2	208000000X	Pediatrics Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417044181
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDCARE PEDIATRICS

Provider Business Mailing Address
First Line	:	910 DANNON VW SW STE 2101
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-2156
Country	:	US
Telephone Number	:	404-691-6100
Fax Number	:	404-691-6959

Provider Business Practice Location Address
First Line	:	910 DANNON VW SW STE 2101
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-2156
Country	:	US
Telephone Number	:	404-691-6100
Fax Number	:	404-691-6959

Authorized Official
Title or Position	:	CEO
Name	:	MR. CHAUNCEY DANIELS
Credential	:
Telephone Number	:	404-765-9437

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	09/16/2020

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Practice Location Address:

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1912343617 — MRS. AMARIS EVANS DANIELS M.D.
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Directions to “KIDCARE PEDIATRICS ” Practice Location

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