1760671572 NPI number — PEDIATRIC SERVICES OF AMERICA, INC

Table of content: (NPI 1760671572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760671572 NPI number — PEDIATRIC SERVICES OF AMERICA, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC SERVICES OF AMERICA, INC
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:
1760671572
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 TECHNOLOGY PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORCROSS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30092-2932
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-441-1580
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 W BROAD AVE
Provider Second Line Business Practice Location Address:
UNIT B-1
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31707-4397
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-435-3387
Provider Business Practice Location Address Fax Number:
229-435-3847
Provider Enumeration Date:
10/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VALENTINE
Authorized Official First Name:
DALE
Authorized Official Middle Name:
Authorized Official Title or Position:
VP COMPLIANCE
Authorized Official Telephone Number:
770-248-8757

Provider Taxonomy Codes

  • Taxonomy code: 251J00000X , with the licence number:  047-R-0377 , 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: 538807248C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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