Provider Demographics
NPI:1619155751
Name:PEDIATRIC CARE AFTER HOURS
Entity Type:Organization
Organization Name:PEDIATRIC CARE AFTER HOURS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:T
Authorized Official - Last Name:BLEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-923-0131
Mailing Address - Street 1:116 S HOUSTON RD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-3904
Mailing Address - Country:US
Mailing Address - Phone:478-923-0131
Mailing Address - Fax:478-922-6530
Practice Address - Street 1:116 S HOUSTON RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-3904
Practice Address - Country:US
Practice Address - Phone:478-923-0131
Practice Address - Fax:478-922-6530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032131208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000400419BMedicaid