Provider Demographics
NPI:1003940909
Name:GWINNETT PEDIATRICS & ADOLESCENT MEDICINE
Entity Type:Organization
Organization Name:GWINNETT PEDIATRICS & ADOLESCENT MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:MAUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-995-0823
Mailing Address - Street 1:595 HURRICANE SHOALS RD NW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046
Mailing Address - Country:US
Mailing Address - Phone:770-995-0823
Mailing Address - Fax:770-995-7018
Practice Address - Street 1:595 HURRICANE SHOALS RD NW
Practice Address - Street 2:SUITE 300
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046
Practice Address - Country:US
Practice Address - Phone:770-995-0823
Practice Address - Fax:770-995-7018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty