Provider Demographics
NPI:1518445410
Name:VILLAGE PEDIATRICS AT VICKERY
Entity Type:Organization
Organization Name:VILLAGE PEDIATRICS AT VICKERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHALINI
Authorized Official - Middle Name:MALA
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-523-8594
Mailing Address - Street 1:6515 WESLEY HUGHES RD
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-6526
Mailing Address - Country:US
Mailing Address - Phone:678-523-8594
Mailing Address - Fax:
Practice Address - Street 1:7185 COLFAX AVEUNE
Practice Address - Street 2:SUITE 200
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040
Practice Address - Country:US
Practice Address - Phone:678-990-3362
Practice Address - Fax:678-550-9587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA68556208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty