NPI age
20 years
Enumerated 2005-09-08
Across 2726 active pediatrics providers in Georgia.
| Type | Value | Notes |
|---|---|---|
| 01 (GA) | 58-1102392 | TAX ID # |
| 01 (SC) | G37310 | SC MEDICAID |
| 01 (GA) | 037310 | STATE LICENSE |
| 05 (GA) | 000554122A |
Part of a multi-provider practice. 12 other active providers share this practice address in NPPES.
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