Provider Demographics
NPI:1447498944
Name:PEDIATRIC AND NEONATAL CLINIC, P.C.
Entity type:Organization
Organization Name:PEDIATRIC AND NEONATAL CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ABOLHASSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:YAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-949-9985
Mailing Address - Street 1:8503 CAMPBELLTON ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-1822
Mailing Address - Country:US
Mailing Address - Phone:770-949-9985
Mailing Address - Fax:770-949-6213
Practice Address - Street 1:8503 CAMPBELLTON ST
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-1822
Practice Address - Country:US
Practice Address - Phone:770-949-9985
Practice Address - Fax:770-949-6213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020501174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000177449EMedicaid