Provider Demographics
NPI:1104034511
Name:EASTMAN PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:EASTMAN PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:R
Authorized Official - Last Name:PEEPLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-374-3814
Mailing Address - Street 1:1223 PLAZA AVE
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-6763
Mailing Address - Country:US
Mailing Address - Phone:478-374-3814
Mailing Address - Fax:478-374-1478
Practice Address - Street 1:1223 PLAZA AVE
Practice Address - Street 2:
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-6763
Practice Address - Country:US
Practice Address - Phone:478-374-3814
Practice Address - Fax:478-374-1478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty