Provider Demographics
NPI:1790943504
Name:PEACH STATE WOMEN'S HEALTHCARE
Entity Type:Organization
Organization Name:PEACH STATE WOMEN'S HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-898-1415
Mailing Address - Street 1:906 HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-6570
Mailing Address - Country:US
Mailing Address - Phone:770-898-1415
Mailing Address - Fax:770-898-2887
Practice Address - Street 1:906 HAMPTON RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6570
Practice Address - Country:US
Practice Address - Phone:770-898-1415
Practice Address - Fax:770-898-2887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025822207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000607945AMedicaid
GA000607945AMedicaid