MEDICARE: PEDIATRIC PARTNERS 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

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	:	1972591238
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC PARTNERS LLC

Provider Business Mailing Address
First Line	:	1520B JENNINGS MILL RD
Second Line	:
City	:	BOGART
State	:	GA
Zip	:	30622-2543
Country	:	US
Telephone Number	:	706-548-1216
Fax Number	:	706-548-1772

Provider Business Practice Location Address
First Line	:	1520B JENNINGS MILL RD
Second Line	:
City	:	BOGART
State	:	GA
Zip	:	30622-2543
Country	:	US
Telephone Number	:	706-548-1216
Fax Number	:	706-548-1772

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DEBBIE L. EUBANKS
Credential	:
Telephone Number	:	706-548-1216

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	08/22/2020

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Directions to “PEDIATRIC PARTNERS LLC ” Practice Location

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