Provider Demographics
NPI:1235388786
Name:THE KID DOCTOR PC
Entity Type:Organization
Organization Name:THE KID DOCTOR PC
Other - Org Name:BRIAN KEITH CHILDERS MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:VOORHEES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-383-4352
Mailing Address - Street 1:100 DOCTORS DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2210
Mailing Address - Country:US
Mailing Address - Phone:912-383-4352
Mailing Address - Fax:912-384-1192
Practice Address - Street 1:100 DOCTORS DR
Practice Address - Street 2:SUITE 104
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2210
Practice Address - Country:US
Practice Address - Phone:912-383-4352
Practice Address - Fax:912-384-1192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042212208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000718792EMedicaid