Provider Demographics
NPI:1083610620
Name:CHILDREN'S CLINIC, LLP
Entity Type:Organization
Organization Name:CHILDREN'S CLINIC, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:S
Authorized Official - Last Name:CARSWELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:478-272-2623
Mailing Address - Street 1:2406 BELLEVUE RD
Mailing Address - Street 2:BLDG 10
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-6105
Mailing Address - Country:US
Mailing Address - Phone:478-272-2623
Mailing Address - Fax:478-272-9984
Practice Address - Street 1:2406 BELLEVUE RD
Practice Address - Street 2:BLDG 10
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-6105
Practice Address - Country:US
Practice Address - Phone:478-272-2623
Practice Address - Fax:478-272-9984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000245572B208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300021882AMedicaid