Provider Demographics
NPI:1942326491
Name:CARTERSVILLE PEDIATRIC ASSOCIATES
Entity Type:Organization
Organization Name:CARTERSVILLE PEDIATRIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-386-3011
Mailing Address - Street 1:PO BOX 200429
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-9008
Mailing Address - Country:US
Mailing Address - Phone:770-386-3011
Mailing Address - Fax:770-386-9451
Practice Address - Street 1:958 JOE FRANK HARRIS PKWY SE
Practice Address - Street 2:SUITE 101
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2174
Practice Address - Country:US
Practice Address - Phone:770-386-3011
Practice Address - Fax:770-386-9451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2016-12-02
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
GA00852024GMedicaid
GA0003129535AMedicaid
GA00214475DMedicaid
GA003174076AMedicaid
GA00328413DMedicaid
GA00520066CMedicaid
GA00214475DMedicaid
GA069850893AMedicaid