Provider Demographics
NPI:1639439631
Name:VALLEY PEDIATRICS
Entity Type:Organization
Organization Name:VALLEY PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:OVERBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-221-6116
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31908-9007
Mailing Address - Country:US
Mailing Address - Phone:706-221-6116
Mailing Address - Fax:706-221-6226
Practice Address - Street 1:5555 WHITTLESEY BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-7212
Practice Address - Country:US
Practice Address - Phone:706-221-6116
Practice Address - Fax:706-221-6226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA67863261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA67863OtherGA MEDICAL LICENSE