Provider Demographics
NPI:1841580420
Name:PEDIATRIC ASSOCITAES OF LAWRENCEVILLE, LLC
Entity Type:Organization
Organization Name:PEDIATRIC ASSOCITAES OF LAWRENCEVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANURADHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHETH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-277-6725
Mailing Address - Street 1:755 OLD NORCROSS RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4317
Mailing Address - Country:US
Mailing Address - Phone:770-277-6725
Mailing Address - Fax:
Practice Address - Street 1:755 OLD NORCROSS RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4317
Practice Address - Country:US
Practice Address - Phone:770-277-6725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-15
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN173289363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty