Provider Demographics
NPI:1801057609
Name:KIDS AVENUE PEDIATRICS LLC
Entity type:Organization
Organization Name:KIDS AVENUE PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:STEMBRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-909-8007
Mailing Address - Street 1:1720 PHOENIX BLVD
Mailing Address - Street 2:SUITE900
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-5594
Mailing Address - Country:US
Mailing Address - Phone:770-909-8007
Mailing Address - Fax:770-909-8005
Practice Address - Street 1:1720 PHOENIX BLVD
Practice Address - Street 2:SUITE900
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-5594
Practice Address - Country:US
Practice Address - Phone:770-909-8007
Practice Address - Fax:770-909-8005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027036208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA497361413AMedicaid