Provider Demographics
NPI:1407864770
Name:VALDOSTA CHILDREN'S HEALTHCARE CENTER ,LLC
Entity Type:Organization
Organization Name:VALDOSTA CHILDREN'S HEALTHCARE CENTER ,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASBIR
Authorized Official - Middle Name:S
Authorized Official - Last Name:GILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-247-7350
Mailing Address - Street 1:105 W CRANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2930
Mailing Address - Country:US
Mailing Address - Phone:229-247-7350
Mailing Address - Fax:229-242-1730
Practice Address - Street 1:105 W CRANFORD AVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2930
Practice Address - Country:US
Practice Address - Phone:229-247-7350
Practice Address - Fax:229-242-1730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX ID