Provider Demographics
NPI:1689290603
Name:IMPACT PHYSICIAN GROUP, PEDIATRICS LLC
Entity Type:Organization
Organization Name:IMPACT PHYSICIAN GROUP, PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-967-5599
Mailing Address - Street 1:21 EASTBROOK BND STE 218
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-1546
Mailing Address - Country:US
Mailing Address - Phone:678-967-5599
Mailing Address - Fax:
Practice Address - Street 1:2720 RUE DE JARDIN STE 100
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4050
Practice Address - Country:US
Practice Address - Phone:260-407-8009
Practice Address - Fax:260-407-8009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-25
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty