Provider Demographics
NPI:1053325027
Name:LOGANVILLE PEDIATRICS & ADOLESCENT CARE ASSOCIATES
Entity type:Organization
Organization Name:LOGANVILLE PEDIATRICS & ADOLESCENT CARE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:TULLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-466-6112
Mailing Address - Street 1:3815 HARRISON RD
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-2462
Mailing Address - Country:US
Mailing Address - Phone:770-466-6112
Mailing Address - Fax:770-466-6201
Practice Address - Street 1:3815 HARRISON RD
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-2462
Practice Address - Country:US
Practice Address - Phone:770-466-6112
Practice Address - Fax:770-466-6201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty