Provider Demographics
NPI:1760671572
Name:PEDIATRIC SERVICES OF AMERICA, INC
Entity Type:Organization
Organization Name:PEDIATRIC SERVICES OF AMERICA, INC
Other - Org Name:PSA HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-248-8757
Mailing Address - Street 1:310 TECHNOLOGY PKWY
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-2932
Mailing Address - Country:US
Mailing Address - Phone:770-441-1580
Mailing Address - Fax:
Practice Address - Street 1:1120 W BROAD AVE
Practice Address - Street 2:UNIT B-1
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-4397
Practice Address - Country:US
Practice Address - Phone:229-435-3387
Practice Address - Fax:229-435-3847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047-R-0377251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA538807248CMedicaid