Provider Demographics
NPI:1720213952
Name:KID STATION PEDIATRICS P.C
Entity Type:Organization
Organization Name:KID STATION PEDIATRICS P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KALYANI
Authorized Official - Middle Name:ANGAMPALLY
Authorized Official - Last Name:RAJEEV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-481-7879
Mailing Address - Street 1:301 MEDICAL DR
Mailing Address - Street 2:SUITE 504
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4144
Mailing Address - Country:US
Mailing Address - Phone:706-882-5437
Mailing Address - Fax:
Practice Address - Street 1:301 MEDICAL DR
Practice Address - Street 2:SUITE 504
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4144
Practice Address - Country:US
Practice Address - Phone:706-882-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-18
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058657208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA416240451HMedicaid