Provider Demographics
NPI:1174838551
Name:THE KIDS SPECIALIST HENRY PEDIATRICS LLC
Entity Type:Organization
Organization Name:THE KIDS SPECIALIST HENRY PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-289-8184
Mailing Address - Street 1:1215 EAGLES LANDING PKWY
Mailing Address - Street 2:SUITE 108 & 109
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7279
Mailing Address - Country:US
Mailing Address - Phone:678-289-8184
Mailing Address - Fax:678-565-9856
Practice Address - Street 1:1215 EAGLES LANDING PKWY
Practice Address - Street 2:SUITE 108 & 109
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7279
Practice Address - Country:US
Practice Address - Phone:678-289-8184
Practice Address - Fax:678-565-9856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045647208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00892746CMedicaid
GA00813942BMedicaid