Provider Demographics
NPI:1518174036
Name:NORTHLAKE PEDIATRIC ASSOCIATES,PC
Entity Type:Organization
Organization Name:NORTHLAKE PEDIATRIC ASSOCIATES,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DELORES
Authorized Official - Middle Name:
Authorized Official - Last Name:TALIAFERRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-498-9355
Mailing Address - Street 1:1805 PARKE PLAZA CIR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3498
Mailing Address - Country:US
Mailing Address - Phone:770-498-9355
Mailing Address - Fax:770-498-6294
Practice Address - Street 1:1805 PARKE PLAZA CIR
Practice Address - Street 2:SUITE 103
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3498
Practice Address - Country:US
Practice Address - Phone:770-498-9355
Practice Address - Fax:770-498-6294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA85000926GMedicaid