Provider Demographics
NPI:1295081321
Name:PERFORMANCE PEDIATRICS AND SPORTS MEDICINE, LLC
Entity type:Organization
Organization Name:PERFORMANCE PEDIATRICS AND SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MERRITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-202-3236
Mailing Address - Street 1:1181 LANGFORD DR
Mailing Address - Street 2:BLDG 200-101
Mailing Address - City:BOGART
Mailing Address - State:GA
Mailing Address - Zip Code:30622-2542
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1181 LANGFORD DR
Practice Address - Street 2:BLDG 200-101
Practice Address - City:BOGART
Practice Address - State:GA
Practice Address - Zip Code:30622-2542
Practice Address - Country:US
Practice Address - Phone:706-207-6694
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-26
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA58543207R00000X, 208000000X, 2080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA58543OtherSTATE MEDICAL LICENSE
GA003125239AMedicaid
GA489449582CMedicaid