Provider Demographics
NPI:1083746838
Name:PEDIATRICS AND ADOLESCENT MEDICINE, PA
Entity Type:Organization
Organization Name:PEDIATRICS AND ADOLESCENT MEDICINE, PA
Other - Org Name:PAMPA
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SEVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-973-4700
Mailing Address - Street 1:PO BOX 102613
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2613
Mailing Address - Country:US
Mailing Address - Phone:770-973-4700
Mailing Address - Fax:770-973-5460
Practice Address - Street 1:2155 POST OAK TRITT RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-8620
Practice Address - Country:US
Practice Address - Phone:770-973-4700
Practice Address - Fax:770-973-5460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA22123208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty