1275165292 NPI number — HEART AND SOUL PEDIATRICS LLC

Table of content: (NPI 1275165292)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275165292 NPI number — HEART AND SOUL PEDIATRICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEART AND SOUL PEDIATRICS LLC
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:
HEART AND SOUL 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:
1275165292
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11770 HAYNES BRIDGE RD
Provider Second Line Business Mailing Address:
SUITE 205 PMB 307
Provider Business Mailing Address City Name:
ALPHARETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30009-1968
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
470-371-3271
Provider Business Mailing Address Fax Number:
770-345-0020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 WALESKA RD STE 1C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30114-2493
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
470-371-3271
Provider Business Practice Location Address Fax Number:
770-345-0020
Provider Enumeration Date:
02/07/2020

Additional Information

Authorized Official

Authorized Official Last Name:
COLON
Authorized Official First Name:
ENID
Authorized Official Middle Name:
Authorized Official Title or Position:
PCP
Authorized Official Telephone Number:
770-345-0055

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1275165292 . This is a "NPI ORGANIZATION" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1306836747 . This is a "NPI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 43020 . This is a "LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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