Provider Demographics
NPI:1821306853
Name:HENRY COUNTY PEDIATRICS, LLC
Entity Type:Organization
Organization Name:HENRY COUNTY PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:
Authorized Official - First Name:ISHRAT
Authorized Official - Middle Name:ARA
Authorized Official - Last Name:HUSSAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-474-6969
Mailing Address - Street 1:125 EAGLES POINTE PKWY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6379
Mailing Address - Country:US
Mailing Address - Phone:770-474-6969
Mailing Address - Fax:770-474-6996
Practice Address - Street 1:125 EAGLES POINTE PKWY
Practice Address - Street 2:SUITE 120
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6379
Practice Address - Country:US
Practice Address - Phone:770-474-6969
Practice Address - Fax:770-474-6996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000892746DMedicaid
GA1851474795OtherPROVIDER NPI