Provider Demographics
NPI:1871707489
Name:COKER PEDIATRICS LLC
Entity type:Organization
Organization Name:COKER PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:COKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-688-1580
Mailing Address - Street 1:14557 HIGHWAY 19
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-9582
Mailing Address - Country:US
Mailing Address - Phone:678-688-1580
Mailing Address - Fax:678-688-1594
Practice Address - Street 1:14557 HIGHWAY 19
Practice Address - Street 2:SUITE A
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-9582
Practice Address - Country:US
Practice Address - Phone:678-688-1580
Practice Address - Fax:678-688-1594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056276208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA579118048JMedicaid
GA218387297BMedicaid
GA604519956BMedicaid
GA218387297AMedicaid
GA604519956AMedicaid
GA579118048HMedicaid
GA579118048EMedicaid
GA003106814AMedicaid
GA487848115CMedicaid