1922276252 NPI number — YOUTHCARE PEDIATRICS OF CENTRAL GEORGIA, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922276252 NPI number — YOUTHCARE PEDIATRICS OF CENTRAL GEORGIA, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YOUTHCARE PEDIATRICS OF CENTRAL GEORGIA, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922276252
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
233 N HOUSTON RD
Provider Second Line Business Mailing Address:
STE 140 H
Provider Business Mailing Address City Name:
WARNER ROBINS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31093-3074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-923-3360
Provider Business Mailing Address Fax Number:
478-923-9977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
233 N HOUSTON RD
Provider Second Line Business Practice Location Address:
SUITE 140-H
Provider Business Practice Location Address City Name:
WARNER ROBINS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31093-3074
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-923-3360
Provider Business Practice Location Address Fax Number:
478-923-9977
Provider Enumeration Date:
02/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WADE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
STEPHEN
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
478-923-3360

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000377836D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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