Provider Demographics
NPI:1225296155
Name:JONESBORO PEDIATRICS
Entity Type:Organization
Organization Name:JONESBORO PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROMEO
Authorized Official - Middle Name:R
Authorized Official - Last Name:MORILES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-478-9240
Mailing Address - Street 1:236 ARROWHEAD BLVD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-1106
Mailing Address - Country:US
Mailing Address - Phone:770-478-9240
Mailing Address - Fax:770-478-0318
Practice Address - Street 1:236 ARROWHEAD BLVD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1106
Practice Address - Country:US
Practice Address - Phone:770-478-9240
Practice Address - Fax:770-478-0318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-28
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000685275BMedicaid
GA000973332BMedicaid
GA107994871AMedicaid
GA000685275CMedicaid
GA000973332AMedicaid
GA107994871BMedicaid