MEDICARE: SOUTH DEKALB 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	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1912107079
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH DEKALB PEDIATRICS

Provider Business Mailing Address
First Line	:	2395 WALL ST SE
Second Line	:	SUITE 700
City	:	CONYERS
State	:	GA
Zip	:	30013-6703
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2395 WALL ST SE
Second Line	:	SUITE 700
City	:	CONYERS
State	:	GA
Zip	:	30013-6703
Country	:	US
Telephone Number	:	404-243-9630
Fax Number	:

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	JORON R. MURRY
Credential	:	CMPE, CPC
Telephone Number	:	404-243-9630

Provider Enumeration Date	:	07/18/2007
Last Update Date	:	07/18/2007

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