Provider Demographics
NPI:1518164755
Name:ST JOSEPH'S PEDIATRICS LLC
Entity Type:Organization
Organization Name:ST JOSEPH'S PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EFFIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:DOLORES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-904-5252
Mailing Address - Street 1:4485 TENCH RD
Mailing Address - Street 2:STE 630
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6739
Mailing Address - Country:US
Mailing Address - Phone:770-904-5252
Mailing Address - Fax:
Practice Address - Street 1:4485 TENCH RD
Practice Address - Street 2:STE 630
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6739
Practice Address - Country:US
Practice Address - Phone:770-904-5252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043598208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000746281EMedicaid