Provider Demographics
NPI:1902200447
Name:PEDIATRIC CLINIC, PC
Entity Type:Organization
Organization Name:PEDIATRIC CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:AMJAD
Authorized Official - Middle Name:
Authorized Official - Last Name:IQBAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-991-8900
Mailing Address - Street 1:189 MEDICAL WAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-4905
Mailing Address - Country:US
Mailing Address - Phone:770-991-8900
Mailing Address - Fax:770-991-8917
Practice Address - Street 1:189 MEDICAL WAY
Practice Address - Street 2:SUITE C
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-4905
Practice Address - Country:US
Practice Address - Phone:770-991-8900
Practice Address - Fax:770-991-8917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20280261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care