Provider Demographics
NPI:1417044181
Name:KIDCARE PEDIATRICS
Entity Type:Organization
Organization Name:KIDCARE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAUNCEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-765-9437
Mailing Address - Street 1:910 DANNON VW SW STE 2101
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-2156
Mailing Address - Country:US
Mailing Address - Phone:404-691-6100
Mailing Address - Fax:404-691-6959
Practice Address - Street 1:910 DANNON VW SW STE 2101
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-2156
Practice Address - Country:US
Practice Address - Phone:404-691-6100
Practice Address - Fax:404-691-6959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X
GA057447302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No302R00000XManaged Care OrganizationsHealth Maintenance OrganizationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000359675HMedicaid