Provider Demographics
NPI:1376096321
Name:DAHLONEGA PEDIATRIC & ADOLESCENT MEDICINE, INC.
Entity Type:Organization
Organization Name:DAHLONEGA PEDIATRIC & ADOLESCENT MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:RNCS, MN, PNP
Authorized Official - Phone:706-864-6700
Mailing Address - Street 1:1055 GROVE ST N
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-3876
Mailing Address - Country:US
Mailing Address - Phone:706-864-6700
Mailing Address - Fax:
Practice Address - Street 1:1055 GROVE ST N
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-3876
Practice Address - Country:US
Practice Address - Phone:706-864-6700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1639298458364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000489189SMedicaid