Provider Demographics
NPI:1376829911
Name:DEKALB PEDIATRIC ASSOCIATES PC
Entity Type:Organization
Organization Name:DEKALB PEDIATRIC ASSOCIATES PC
Other - Org Name:HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-446-4600
Mailing Address - Street 1:1390 MONTREAL RD STE 180
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-8187
Mailing Address - Country:US
Mailing Address - Phone:404-446-4600
Mailing Address - Fax:404-446-4601
Practice Address - Street 1:1390 MONTREAL RD STE 180
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-8187
Practice Address - Country:US
Practice Address - Phone:404-446-4600
Practice Address - Fax:404-446-4601
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEKALB PEDIATRIC ASSOCIATES PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050105208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000940266KMedicaid