Provider Demographics
NPI:1063679207
Name:PEDIATRICS OF DALTON, PA
Entity Type:Organization
Organization Name:PEDIATRICS OF DALTON, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOCKERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-278-5373
Mailing Address - Street 1:1409 CHATTANOOGA AVE
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2631
Mailing Address - Country:US
Mailing Address - Phone:706-278-5373
Mailing Address - Fax:706-278-5085
Practice Address - Street 1:1409 CHATTANOOGA AVE
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2631
Practice Address - Country:US
Practice Address - Phone:706-278-5373
Practice Address - Fax:706-278-5085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA015426174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA30019480AMedicaid