Provider Demographics
NPI:1093982746
Name:LUCAS PEDIATRICS, PC
Entity Type:Organization
Organization Name:LUCAS PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-645-2250
Mailing Address - Street 1:622 W CROSSVILLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-2560
Mailing Address - Country:US
Mailing Address - Phone:770-645-2250
Mailing Address - Fax:770-643-5850
Practice Address - Street 1:622 W CROSSVILLE RD STE 100
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-2560
Practice Address - Country:US
Practice Address - Phone:770-645-2250
Practice Address - Fax:770-643-5850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038040208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000580016EMedicaid