Provider Demographics
NPI:1295834380
Name:CARROLLTON PEDIATRIC CLINIC, P.C.
Entity Type:Organization
Organization Name:CARROLLTON PEDIATRIC CLINIC, P.C.
Other - Org Name:WESTCARE PEDIATRIC AND FAMILY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-832-1103
Mailing Address - Street 1:410 NEWNAN ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3111
Mailing Address - Country:US
Mailing Address - Phone:770-832-1103
Mailing Address - Fax:770-832-1142
Practice Address - Street 1:410 NEWNAN ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3111
Practice Address - Country:US
Practice Address - Phone:770-832-1103
Practice Address - Fax:770-832-1142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11D0934505OtherCLIA
GA300025719AMedicaid
GA300025719AMedicaid