Provider Demographics
NPI:1710267505
Name:MOUNTAINSIDE PEDIATRICS
Entity Type:Organization
Organization Name:MOUNTAINSIDE PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KHAWAJA
Authorized Official - Middle Name:RAZA
Authorized Official - Last Name:MAHMOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-253-9898
Mailing Address - Street 1:12 SAMMY MCGHEE BOULAVARD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-7711
Mailing Address - Country:US
Mailing Address - Phone:706-253-9898
Mailing Address - Fax:706-253-9896
Practice Address - Street 1:12 SAMMY MCGHEE BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-7711
Practice Address - Country:US
Practice Address - Phone:706-253-9898
Practice Address - Fax:706-253-9896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA42648261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care