1518174036 NPI number — NORTHLAKE PEDIATRIC ASSOCIATES,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 1518174036 NPI number — NORTHLAKE PEDIATRIC ASSOCIATES,PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHLAKE PEDIATRIC ASSOCIATES,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:
Provider Other Organization Name Type Code:
6
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:
1518174036
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1805 PARKE PLAZA CIR
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
STONE MOUNTAIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30087-3498
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-498-9355
Provider Business Mailing Address Fax Number:
770-498-6294

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1805 PARKE PLAZA CIR
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
STONE MOUNTAIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30087-3498
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-498-9355
Provider Business Practice Location Address Fax Number:
770-498-6294
Provider Enumeration Date:
05/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TALIAFERRO
Authorized Official First Name:
DELORES
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
770-498-9355

Provider Taxonomy Codes

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

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

  • Identifier: 85000926G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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