MEDICARE: KIDS TIME PEDIATRICS OF SOUTHERN CRESCENT, 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	2080A0000X	Pediatric Adolescent Medicine Physician

General Provider Information

NPI Number	:	1447383351
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS TIME PEDIATRICS OF SOUTHERN CRESCENT, LLC

Provider Business Mailing Address
First Line	:	696 BILLUPS AVE
Second Line	:
City	:	MADISON
State	:	GA
Zip	:	30650-1439
Country	:	US
Telephone Number	:	706-342-2180
Fax Number	:

Provider Business Practice Location Address
First Line	:	115 SUMNER RD
Second Line	:	SUITE D
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-4758
Country	:	US
Telephone Number	:	706-342-2180
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	FLYNN CLYBURN
Credential	:
Telephone Number	:	706-342-2180

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	08/22/2020

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