Provider Demographics
NPI:1043495963
Name:BEACON PEDIATRICS
Entity Type:Organization
Organization Name:BEACON PEDIATRICS
Other - Org Name:DAVID H. CHEATHAM, M.D.,P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KITTY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LPN, RMM
Authorized Official - Phone:912-285-2440
Mailing Address - Street 1:801 BEACON ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-7109
Mailing Address - Country:US
Mailing Address - Phone:912-285-2440
Mailing Address - Fax:912-287-0197
Practice Address - Street 1:801 BEACON ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-7109
Practice Address - Country:US
Practice Address - Phone:912-285-2440
Practice Address - Fax:912-287-0197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045745261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000797024DMedicaid