Provider Demographics
NPI:1548242076
Name:CHILD, CLELAND G (MD)
Entity Type:Individual
Prefix:
First Name:CLELAND
Middle Name:G
Last Name:CHILD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 NEWNAN CROSSING BLVD E
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2408
Mailing Address - Country:US
Mailing Address - Phone:770-400-7700
Mailing Address - Fax:
Practice Address - Street 1:2401 NEWNAN CROSSING BLVD E
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2408
Practice Address - Country:US
Practice Address - Phone:770-400-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030589207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00408768FMedicaid
GA11BDGJMMedicare ID - Type Unspecified
GA00408768FMedicaid