Provider Demographics
NPI:1881809937
Name:VERRAS PEDIATRICS PC
Entity type:Organization
Organization Name:VERRAS PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ATHANASIOS
Authorized Official - Middle Name:
Authorized Official - Last Name:VERRAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-491-1285
Mailing Address - Street 1:2181 NORTHLAKE PKWY
Mailing Address - Street 2:BLDG 6 SUITE 104
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4107
Mailing Address - Country:US
Mailing Address - Phone:770-491-1285
Mailing Address - Fax:770-491-3164
Practice Address - Street 1:2181 NORTHLAKE PKWY
Practice Address - Street 2:BLDG 6 SUITE 104
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4107
Practice Address - Country:US
Practice Address - Phone:770-491-1285
Practice Address - Fax:770-491-3164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022908208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1508824392OtherNPI
F32104Medicare UPIN