Provider Demographics
NPI:1669729257
Name:MEADOW PEDIATRICS, PLLC
Entity type:Organization
Organization Name:MEADOW PEDIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SRIDEVI
Authorized Official - Middle Name:
Authorized Official - Last Name:MUTHUKUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-707-8359
Mailing Address - Street 1:10710 MEDLOCK BRIDGE RD STE 250
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-1827
Mailing Address - Country:US
Mailing Address - Phone:310-707-8359
Mailing Address - Fax:770-825-9001
Practice Address - Street 1:10710 MEDLOCK BRIDGE RD STE 250
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-1827
Practice Address - Country:US
Practice Address - Phone:310-707-8359
Practice Address - Fax:770-825-9001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA63377208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA558938842BMedicaid