Provider Demographics
NPI:1396738381
Name:WELLSTAR MEDICAL GROUP EAST PAULDING PEDIATRICS
Entity type:Organization
Organization Name:WELLSTAR MEDICAL GROUP EAST PAULDING PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVILLIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-945-8320
Mailing Address - Street 1:51 HIRAM DR
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-1844
Mailing Address - Country:US
Mailing Address - Phone:678-945-8300
Mailing Address - Fax:770-445-2020
Practice Address - Street 1:51 HIRAM DR
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-1844
Practice Address - Country:US
Practice Address - Phone:678-945-8300
Practice Address - Fax:770-445-2020
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLSTAR MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-25
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024912174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1420565Medicaid
GA1899964650AMedicaid