Provider Demographics
NPI:1265605190
Name:ATHENS PEDIATRICS P.C.
Entity type:Organization
Organization Name:ATHENS PEDIATRICS P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRIS
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:ACKAOUY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-745-5955
Mailing Address - Street 1:111 EPPERSON ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TN
Mailing Address - Zip Code:37303-3478
Mailing Address - Country:US
Mailing Address - Phone:423-745-5955
Mailing Address - Fax:423-745-6423
Practice Address - Street 1:111 EPPERSON ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-3478
Practice Address - Country:US
Practice Address - Phone:423-745-5955
Practice Address - Fax:423-745-6423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD32738208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3171521Medicaid