1669729257 NPI number — MEADOW PEDIATRICS, PLLC

Table of content: (NPI 1669729257)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669729257 NPI number — MEADOW PEDIATRICS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEADOW PEDIATRICS, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669729257
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10710 MEDLOCK BRIDGE RD STE 250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNS CREEK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30097-1827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-707-8359
Provider Business Mailing Address Fax Number:
770-825-9001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10710 MEDLOCK BRIDGE RD STE 250
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNS CREEK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30097-1827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-707-8359
Provider Business Practice Location Address Fax Number:
770-825-9001
Provider Enumeration Date:
08/14/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MUTHUKUMAR
Authorized Official First Name:
SRIDEVI
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
310-707-8359

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  63377 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 558938842B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com