Provider Demographics
NPI:1831500370
Name:GRAYSON PEDIATRICS, LLC
Entity Type:Organization
Organization Name:GRAYSON PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP, CFO
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:OPEKA
Authorized Official - Suffix:
Authorized Official - Credentials:CPNP
Authorized Official - Phone:678-381-2630
Mailing Address - Street 1:297 COOPER RD
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-2518
Mailing Address - Country:US
Mailing Address - Phone:678-381-2630
Mailing Address - Fax:678-381-2627
Practice Address - Street 1:297 COOPER RD
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-2518
Practice Address - Country:US
Practice Address - Phone:678-381-2630
Practice Address - Fax:678-381-2627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-19
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057218208000000X
GARN154025363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003191294BMedicaid
GA1831365964Medicaid
GA452405206MMedicaid
GA003215265AMedicaid
GA003109575EMedicaid
GA003172811DMedicaid
GA003172811AMedicaid