MEDICARE: GC DULUTH PEDIATRICS, INC.

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	049206	GA

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	:	1922374297
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GC DULUTH PEDIATRICS, INC.

Provider Business Mailing Address
First Line	:	3435 DULUTH PARK LN STE A
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-3259
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3435 DULUTH PARK LN STE A
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-3259
Country	:	US
Telephone Number	:	678-417-0407
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SAMUEL SONG
Credential	:
Telephone Number	:	678-417-0407

Provider Enumeration Date	:	03/30/2012
Last Update Date	:	03/30/2012

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