Provider Demographics
NPI:1932389608
Name:PEDIATRIC ENDOCRINE ASSOCIATES, PC
Entity Type:Organization
Organization Name:PEDIATRIC ENDOCRINE ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:SPANGLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-255-1267
Mailing Address - Street 1:1100 LAKE HEARN DR NE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1523
Mailing Address - Country:US
Mailing Address - Phone:404-255-0015
Mailing Address - Fax:404-845-3080
Practice Address - Street 1:1100 LAKE HEARN DR NE
Practice Address - Street 2:SUITE 350
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1523
Practice Address - Country:US
Practice Address - Phone:404-255-0015
Practice Address - Fax:404-845-3080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA259352080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric EndocrinologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00313365AMedicaid
GA18949Medicaid
GA00709541AMedicaid
GA1386608404Medicare UPIN
GA18949Medicaid
GA00709541AMedicaid
GA00313365AMedicaid
GAG65529Medicare UPIN
GAD41068Medicare UPIN
1619931490Medicare UPIN
GA1376507145Medicare UPIN