Provider Demographics
NPI:1831217157
Name:CONYERS PEDIATRICS, PC
Entity type:Organization
Organization Name:CONYERS PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:W
Authorized Official - Last Name:SENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-922-5745
Mailing Address - Street 1:1277B WELLBROOK CIR NE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3873
Mailing Address - Country:US
Mailing Address - Phone:770-922-5745
Mailing Address - Fax:770-922-4924
Practice Address - Street 1:1277B WELLBROOK CIR NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3873
Practice Address - Country:US
Practice Address - Phone:770-922-5745
Practice Address - Fax:770-922-4924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA85000351GMedicaid
GA4544OtherAETNA