Provider Demographics
NPI:1174813737
Name:PEDIATRIC CARDIOLOGY SERVICES, LLC
Entity Type:Organization
Organization Name:PEDIATRIC CARDIOLOGY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NEILL
Authorized Official - Middle Name:
Authorized Official - Last Name:VIDELEFSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-995-6684
Mailing Address - Street 1:500 MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE 390
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-8708
Mailing Address - Country:US
Mailing Address - Phone:770-995-6684
Mailing Address - Fax:770-995-7631
Practice Address - Street 1:500 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 390
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8708
Practice Address - Country:US
Practice Address - Phone:770-995-6684
Practice Address - Fax:770-995-7631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-15
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000740891AMedicaid
GA000326873GMedicaid