Provider Demographics
NPI:1891065504
Name:CAMP CREEK PEDIATRICS
Entity Type:Organization
Organization Name:CAMP CREEK PEDIATRICS
Other - Org Name:CHARLENE JOHNSON, MD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DYSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-745-1070
Mailing Address - Street 1:2945 STONE HOGAN CONNECTOR RD SW STE 201
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-2839
Mailing Address - Country:US
Mailing Address - Phone:404-349-6758
Mailing Address - Fax:404-349-6759
Practice Address - Street 1:495 VIRGINIA HIGHLANDS
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-8233
Practice Address - Country:US
Practice Address - Phone:770-460-6459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049655208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty