Provider Demographics
NPI:1922127851
Name:DAHLONEGA PEDIATRIC & ADOLESCENT MEDICINE
Entity Type:Organization
Organization Name:DAHLONEGA PEDIATRIC & ADOLESCENT MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-864-6700
Mailing Address - Street 1:1055 GROVE ST N
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-3876
Mailing Address - Country:US
Mailing Address - Phone:706-864-6700
Mailing Address - Fax:706-864-2599
Practice Address - Street 1:1055 GROVE ST N
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-3876
Practice Address - Country:US
Practice Address - Phone:706-864-6700
Practice Address - Fax:706-864-2599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033810261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX IDENTIFICATION NUMBER