1538191820 NPI number — PEDIATRIC SERVICES OF AMERICA, LLC

Table of content: (NPI 1538191820)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538191820 NPI number — PEDIATRIC SERVICES OF AMERICA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC SERVICES OF AMERICA, 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:
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:
1538191820
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 INTERSTATE NORTH PKWY SE STE 1600
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30339-5047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
470-464-8000
Provider Business Mailing Address Fax Number:
770-248-8192

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4408 COLUMBIA RD
Provider Second Line Business Practice Location Address:
UNITS 100 & 102
Provider Business Practice Location Address City Name:
MARTINEZ
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30907-4554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-868-6543
Provider Business Practice Location Address Fax Number:
706-868-9754
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUCKHALTER
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
470-464-8000

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  121-R-0003 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251J00000X , with the licence number: 121-265H , 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: 538807248D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00974278A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 538807248B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: EX0445 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 538807248E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: EXG033 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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