Provider Demographics
NPI:1629025432
Name:THE PEDIATRIC OFFICE, LLC
Entity Type:Organization
Organization Name:THE PEDIATRIC OFFICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KEELYN
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-854-2600
Mailing Address - Street 1:4321 UNIVERSITY PKWY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3058
Mailing Address - Country:US
Mailing Address - Phone:706-854-2600
Mailing Address - Fax:706-854-2601
Practice Address - Street 1:4321 UNIVERSITY PKWY
Practice Address - Street 2:SUITE 104
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3058
Practice Address - Country:US
Practice Address - Phone:706-854-2600
Practice Address - Fax:706-854-2601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300035984AMedicaid