Provider Demographics
NPI:1609036532
Name:PEDIATRIC ORTHOPAEDIC ASSOCIATES
Entity type:Organization
Organization Name:PEDIATRIC ORTHOPAEDIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GULLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-321-9900
Mailing Address - Street 1:6 EXECUTIVE PARK DR NE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2221
Mailing Address - Country:US
Mailing Address - Phone:404-321-9900
Mailing Address - Fax:404-321-4460
Practice Address - Street 1:6 EXECUTIVE PARK DR NE
Practice Address - Street 2:SUITE 10
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2221
Practice Address - Country:US
Practice Address - Phone:404-321-9900
Practice Address - Fax:404-321-4460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-13
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00010591174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000119578EMedicaid
GA000053237CMedicaid
GA000867787AMedicaid
GA000612598FMedicaid
GA000944523AMedicaid