Provider Demographics
NPI:1639297401
Name:GWENDOLYN A. DELANEY, M.D. LLC
Entity Type:Organization
Organization Name:GWENDOLYN A. DELANEY, M.D. LLC
Other - Org Name:VICKERY PEDIATRICS AND ADOLESCENT MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DELANEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-990-2501
Mailing Address - Street 1:410 PEACHTREE PKWY STE 4260
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7407
Mailing Address - Country:US
Mailing Address - Phone:678-990-2501
Mailing Address - Fax:678-990-2505
Practice Address - Street 1:410 PEACHTREE PKWY STE 4260
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7407
Practice Address - Country:US
Practice Address - Phone:678-990-2501
Practice Address - Fax:678-990-2505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0493802080A0000X
GA0515192080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000885431QMedicaid