1831500370 NPI number — GRAYSON PEDIATRICS, LLC

Table of content: (NPI 1831500370)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831500370 NPI number — GRAYSON PEDIATRICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAYSON 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:
Provider Other Organization Name Type Code:
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:
1831500370
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
297 COOPER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOGANVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30052-2518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-381-2630
Provider Business Mailing Address Fax Number:
678-381-2627

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
297 COOPER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGANVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30052-2518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-381-2630
Provider Business Practice Location Address Fax Number:
678-381-2627
Provider Enumeration Date:
05/19/2014

Additional Information

Authorized Official

Authorized Official Last Name:
OPEKA
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
NP, CFO
Authorized Official Telephone Number:
678-381-2630

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  057218 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP0200X , with the licence number: RN154025 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 003191294B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1831365964 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 452405206M , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003215265A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003109575E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003172811D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003172811A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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