Provider Demographics
NPI:1356694806
Name:BRANNON PEDIATRIC SERVICES, INC.
Entity type:Organization
Organization Name:BRANNON PEDIATRIC SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-503-7337
Mailing Address - Street 1:634 TOMMY AARON DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-1504
Mailing Address - Country:US
Mailing Address - Phone:770-503-7337
Mailing Address - Fax:
Practice Address - Street 1:634 TOMMY AARON DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506-1504
Practice Address - Country:US
Practice Address - Phone:770-503-7337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-22
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1407055692Medicaid
GA1770653297Medicaid
GA1225346299Medicaid
GA1811019326Medicaid
GA1174645725Medicaid
GA1679639355Medicaid