Provider Demographics
NPI:1578742516
Name:PRIMARY CARE PEDIATRICS, P.C.
Entity Type:Organization
Organization Name:PRIMARY CARE PEDIATRICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:BOUDREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-208-2049
Mailing Address - Street 1:763 PEACHTREE PKWY STE 2
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-9351
Mailing Address - Country:US
Mailing Address - Phone:678-208-2050
Mailing Address - Fax:678-208-2051
Practice Address - Street 1:763 PEACHTREE PKWY STE 2
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-9351
Practice Address - Country:US
Practice Address - Phone:678-208-2050
Practice Address - Fax:678-208-2051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-26
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care