Provider Demographics
NPI:1457539090
Name:PEDIATRIA HEALTHCARE, LLC
Entity Type:Organization
Organization Name:PEDIATRIA HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF BUSINESS OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KILINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-840-1966
Mailing Address - Street 1:5185 PEACHTREE PKWY
Mailing Address - Street 2:STE 350
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-6542
Mailing Address - Country:US
Mailing Address - Phone:770-840-1966
Mailing Address - Fax:770-840-1901
Practice Address - Street 1:1967 LAKESIDE PKWY
Practice Address - Street 2:SUITE 420
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5867
Practice Address - Country:US
Practice Address - Phone:770-414-0055
Practice Address - Fax:770-414-0045
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIA HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-06
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACCLC-18589261QM3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA656991060BMedicaid