Provider Demographics
NPI:1225111594
Name:PEDIATRIC & ADOLESCENT CLINIC, LLC
Entity Type:Organization
Organization Name:PEDIATRIC & ADOLESCENT CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MEGOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-259-4905
Mailing Address - Street 1:PO BOX 1666
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31603-1666
Mailing Address - Country:US
Mailing Address - Phone:229-259-4905
Mailing Address - Fax:
Practice Address - Street 1:2501 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1735
Practice Address - Country:US
Practice Address - Phone:229-259-4905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty