Provider Demographics
NPI:1053578450
Name:PRIME PEDIATRICS PC
Entity type:Organization
Organization Name:PRIME PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHADWICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-279-1994
Mailing Address - Street 1:1610 BROADRICK DR
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-3012
Mailing Address - Country:US
Mailing Address - Phone:706-279-1994
Mailing Address - Fax:706-279-9229
Practice Address - Street 1:1610 BROADRICK DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-3012
Practice Address - Country:US
Practice Address - Phone:706-279-1994
Practice Address - Fax:706-279-9229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA378962080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000910214AMedicaid
GA000572525CMedicaid
GA964266319AMedicaid
GA803486775AMedicaid