Provider Demographics
NPI:1841402781
Name:WOODSTOCK PEDIATRIC MEDICINE
Entity Type:Organization
Organization Name:WOODSTOCK PEDIATRIC MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARULANDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-517-0250
Mailing Address - Street 1:2000 PROFESSIONAL WAY
Mailing Address - Street 2:BLDG 200
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-4093
Mailing Address - Country:US
Mailing Address - Phone:770-517-0250
Mailing Address - Fax:770-517-0260
Practice Address - Street 1:2000 PROFESSIONAL WAY
Practice Address - Street 2:BLDG 200
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4093
Practice Address - Country:US
Practice Address - Phone:770-517-0250
Practice Address - Fax:770-517-0260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA085001488GMedicaid