Provider Demographics
NPI:1366721706
Name:PEDIATRIC ENDOCRINE SPECIALISTS OF GEORGIA
Entity type:Organization
Organization Name:PEDIATRIC ENDOCRINE SPECIALISTS OF GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:BERNARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-374-1646
Mailing Address - Street 1:10700 MEDLOCK BRIDGE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-8456
Mailing Address - Country:US
Mailing Address - Phone:678-691-5351
Mailing Address - Fax:770-685-1241
Practice Address - Street 1:10700 MEDLOCK BRIDGE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-8456
Practice Address - Country:US
Practice Address - Phone:678-691-5351
Practice Address - Fax:770-685-1241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA600452080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric EndocrinologyGroup - Single Specialty