Provider Demographics
NPI:1881850139
Name:THOMASTON PEDIATRICS PC
Entity type:Organization
Organization Name:THOMASTON PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:DELLI-GATTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-647-1680
Mailing Address - Street 1:403 W GORDON ST
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-3423
Mailing Address - Country:US
Mailing Address - Phone:706-647-1680
Mailing Address - Fax:706-646-3125
Practice Address - Street 1:403 W GORDON ST
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-3423
Practice Address - Country:US
Practice Address - Phone:706-647-1680
Practice Address - Fax:706-646-3125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-05
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0003048078AOtherPEACH STATE HEALTH PLAN
GA000304807AMedicaid
GA319469OtherWELLCARE OF GEORGIA