MEDICARE: VALLEY 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	261QP2300X	Primary Care Clinic/Center	67863	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	67863	OTHER	GA	GA MEDICAL LICENSE

General Provider Information

NPI Number	:	1639439631
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VALLEY PEDIATRICS

Provider Business Mailing Address
First Line	:	PO BOX 9007
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31908-9007
Country	:	US
Telephone Number	:	706-221-6116
Fax Number	:	706-221-6226

Provider Business Practice Location Address
First Line	:	5555 WHITTLESEY BLVD
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31909-7212
Country	:	US
Telephone Number	:	706-221-6116
Fax Number	:	706-221-6226

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. BEN OVERBY
Credential	:
Telephone Number	:	706-221-6116

Provider Enumeration Date	:	05/23/2012
Last Update Date	:	05/23/2012

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Directions to “VALLEY PEDIATRICS ” Practice Location

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