Provider Demographics
NPI:1700114519
Name:KIDS FIRST PEDIATRIC GROUP OF AUGUSTA,INC.
Entity Type:Organization
Organization Name:KIDS FIRST PEDIATRIC GROUP OF AUGUSTA,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:THOMPSON-ARMANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-650-0004
Mailing Address - Street 1:1215 GEORGE C.WILSON CT.
Mailing Address - Street 2:SUITE B1
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-5700
Mailing Address - Country:US
Mailing Address - Phone:706-650-0004
Mailing Address - Fax:706-650-5889
Practice Address - Street 1:1215 GEORGE C.WILSON CT.
Practice Address - Street 2:SUITE B1
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-5700
Practice Address - Country:US
Practice Address - Phone:706-650-0004
Practice Address - Fax:706-650-5889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-07
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056931208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA865263766AMedicaid