Provider Demographics
NPI:1184891400
Name:PEDIATRICS AT WHITLOCK P.C.
Entity type:Organization
Organization Name:PEDIATRICS AT WHITLOCK P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:POOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-499-8909
Mailing Address - Street 1:611 CAMPBELL HILL ST NW STE 103
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1386
Mailing Address - Country:US
Mailing Address - Phone:770-499-8909
Mailing Address - Fax:770-499-8911
Practice Address - Street 1:611 CAMPBELL HILL ST NW STE 103
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1386
Practice Address - Country:US
Practice Address - Phone:770-499-8909
Practice Address - Fax:770-499-8911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047011261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1003983693OtherDR. STEPHANIE L. POOLE'S NPI
GA000949044DMedicaid