Provider Demographics
NPI:1548385941
Name:MCDONOUGH CHILDREN'S SPECIALIST, P.C.
Entity Type:Organization
Organization Name:MCDONOUGH CHILDREN'S SPECIALIST, P.C.
Other - Org Name:JOSEPH ASTACIO, M.D..P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:ASTACIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-957-3393
Mailing Address - Street 1:PO BOX 1720
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-1749
Mailing Address - Country:US
Mailing Address - Phone:770-957-3393
Mailing Address - Fax:
Practice Address - Street 1:350 HUNTINGTON PLACE CT
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-8651
Practice Address - Country:US
Practice Address - Phone:770-957-3393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA85002370GMedicaid