Provider Demographics
NPI:1447699061
Name:WEST VININGS PEDIATRIC GROUP, P.C.
Entity type:Organization
Organization Name:WEST VININGS PEDIATRIC GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:L/
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-446-3960
Mailing Address - Street 1:3644 HIGHLANDS PKWY SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-5184
Mailing Address - Country:US
Mailing Address - Phone:404-446-3960
Mailing Address - Fax:404-446-3965
Practice Address - Street 1:3644 HIGHLANDS PKWY SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-5184
Practice Address - Country:US
Practice Address - Phone:404-446-3960
Practice Address - Fax:404-446-3965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050747208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA683835419DMedicaid