1104159086 NPI number — WOODSTOCK PEDIATRICS PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104159086 NPI number — WOODSTOCK PEDIATRICS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOODSTOCK PEDIATRICS PC
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:
MAIN STREET PEDIATRICS
Provider Other Organization Name Type Code:
3
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:
1104159086
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
460 W MAIN ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
BLUE RIDGE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30513-7127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-632-0330
Provider Business Mailing Address Fax Number:
706-632-9004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
460 W MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BLUE RIDGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30513-7127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-632-0330
Provider Business Practice Location Address Fax Number:
706-632-9004
Provider Enumeration Date:
09/10/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
T
Authorized Official Title or Position:
M.D.
Authorized Official Telephone Number:
706-632-0330

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  032063 , 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: 000448269F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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