Provider Demographics
NPI:1003077876
Name:PEDIATRIC CARDIOLOGY SERVICES LLC
Entity Type:Organization
Organization Name:PEDIATRIC CARDIOLOGY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODY
Authorized Official - Suffix:
Authorized Official - Credentials:RMM
Authorized Official - Phone:770-995-6684
Mailing Address - Street 1:500 MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-8708
Mailing Address - Country:US
Mailing Address - Phone:770-995-6684
Mailing Address - Fax:770-995-7631
Practice Address - Street 1:200 S ENOTA DR NE
Practice Address - Street 2:SUITE 380
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3473
Practice Address - Country:US
Practice Address - Phone:770-995-6684
Practice Address - Fax:770-995-7631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0432982080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00740891AMedicaid
GA000326873GMedicaid