Provider Demographics
NPI:1346419710
Name:KIDS & TEENS PRIMARY HEALTHCARE
Entity Type:Organization
Organization Name:KIDS & TEENS PRIMARY HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BYRON
Authorized Official - Middle Name:CEDRIC
Authorized Official - Last Name:COTTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FAAP
Authorized Official - Phone:770-621-0245
Mailing Address - Street 1:2785 LAWRENCEVILLE HWY
Mailing Address - Street 2:SUITE 207
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033
Mailing Address - Country:US
Mailing Address - Phone:770-621-0245
Mailing Address - Fax:770-621-0819
Practice Address - Street 1:2785 LAWRENCEVILLE HWY
Practice Address - Street 2:SUITE 207
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033
Practice Address - Country:US
Practice Address - Phone:770-621-0245
Practice Address - Fax:770-621-0819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041098207QA0000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000679731NMedicaid