NPIMap

Organization Active NPI

Performance Pediatrics and Sports Medicine, LLC

  • Pediatric Sports Medicine Physician
  • Bogart, GA
National Provider Identifier
1295081321
Registry record updated Jul 26, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric Sports Medicine PhysicianTaxonomy code 2080S0010X
License
58543 Issued in GA
Legal business name
PERFORMANCE PEDIATRICS AND SPORTS MEDICINE, LLC
Practice address
1181 Langford Dr
BLDG 200-101
Bogart, GA 30622-2542
Phone
(706) 207-6694
NPI assigned
Jul 26, 2012
Last updated
Jul 26, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 26, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Tara Ann Merritt, M.D.
Title
Owner Physician
Phone
(706) 202-3236

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X 58543 GA
Pediatrics Physician 208000000X 58543 GA
Pediatric Sports Medicine Physician 2080S0010X 58543 GA Primary

Addresses

Primary practice location

1181 Langford Dr
BLDG 200-101
Bogart, GA 30622-2542

Mailing address

1181 Langford Dr
BLDG 200-101
Bogart, GA 30622-2542

Other identifiers 3

IdentifierTypeStateIssuer
58543OtherGASTATE MEDICAL LICENSE
489449582CMedicaidGA
003125239AMedicaidGA

National Provider Directory

National Provider Directory

Interoperability endpoints

  • FHIR API: https://api.platform.athenahealth.com/4861/brand/1/csg/1/fhir/r4

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1343260800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1343260800000",
    "number": "1295081321",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1181 LANGFORD DR",
            "address_2": "BLDG 200-101",
            "city": "BOGART",
            "state": "GA",
            "postal_code": "306222542"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1181 LANGFORD DR",
            "address_2": "BLDG 200-101",
            "city": "BOGART",
            "state": "GA",
            "postal_code": "306222542",
            "telephone_number": "706-207-6694"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PERFORMANCE PEDIATRICS AND SPORTS MEDICINE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-07-26",
        "last_updated": "2012-07-26",
        "status": "A",
        "authorized_official_last_name": "MERRITT",
        "authorized_official_first_name": "TARA",
        "authorized_official_middle_name": "ANN",
        "authorized_official_title_or_position": "OWNER PHYSICIAN",
        "authorized_official_telephone_number": "706-202-3236",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "GA",
            "license": "58543",
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "GA",
            "license": "58543",
            "primary": false
        },
        {
            "code": "2080S0010X",
            "taxonomy_group": "",
            "desc": "Pediatrics, Sports Medicine",
            "state": "GA",
            "license": "58543",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE MEDICAL LICENSE",
            "identifier": "58543",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "489449582C",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003125239A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Bogart, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 26, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.