Provider Demographics
NPI:1013079987
Name:PEDIATRIC HEALTH CENTER OF CONYERS, PC
Entity Type:Organization
Organization Name:PEDIATRIC HEALTH CENTER OF CONYERS, PC
Other - Org Name:PEDIATRIC HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER, SEC/TREAS OF PC
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLADYS
Authorized Official - Middle Name:H
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:BSN
Authorized Official - Phone:678-336-5255
Mailing Address - Street 1:4243 DUNWOODY CLUB DR
Mailing Address - Street 2:STE 103
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30350-5206
Mailing Address - Country:US
Mailing Address - Phone:678-336-5255
Mailing Address - Fax:770-760-7200
Practice Address - Street 1:4243 DUNWOODY CLUB DR STE 103
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30350-5206
Practice Address - Country:US
Practice Address - Phone:678-336-5255
Practice Address - Fax:678-336-5259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2022-07-21
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
GA000068912EMedicaid
GA000945051BMedicaid
GA000068912EMedicaid
GAI23242Medicare UPIN