Provider Demographics
NPI:1487782942
Name:PEACHTREE PEDIATRICS, PLLC
Entity type:Organization
Organization Name:PEACHTREE PEDIATRICS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:GIBSON
Authorized Official - Last Name:WAGGONER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:828-837-2128
Mailing Address - Street 1:125 MEDICAL PARK LN
Mailing Address - Street 2:SUITE F
Mailing Address - City:MURPHY
Mailing Address - State:NC
Mailing Address - Zip Code:28906-6920
Mailing Address - Country:US
Mailing Address - Phone:828-837-2128
Mailing Address - Fax:828-837-6244
Practice Address - Street 1:125 MEDICAL PARK LN
Practice Address - Street 2:SUITE F
Practice Address - City:MURPHY
Practice Address - State:NC
Practice Address - Zip Code:28906-6920
Practice Address - Country:US
Practice Address - Phone:828-837-2128
Practice Address - Fax:828-837-6244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89012C7Medicaid