Provider Demographics
NPI:1518972348
Name:TMC CHILDREN'S HEALTHCARE OF WEST GEORGIA
Entity type:Organization
Organization Name:TMC CHILDREN'S HEALTHCARE OF WEST GEORGIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:DREILING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-838-8038
Mailing Address - Street 1:148 CLINIC AVE
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4414
Mailing Address - Country:US
Mailing Address - Phone:770-838-8640
Mailing Address - Fax:770-838-8650
Practice Address - Street 1:148 CLINIC AVE
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4414
Practice Address - Country:US
Practice Address - Phone:770-838-8640
Practice Address - Fax:770-838-8650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300035885COtherMEDICAID PAYEE
GA300035885AOtherMEDICAID PAYEE
GA300035885BOtherMEDICAID PAYEE