NPIMap

Organization Active NPI

Kids-Doc-on-Wheels

  • Pediatrics Physician
  • Clarkston, GA
National Provider Identifier
1497277404
Registry record updated Dec 14, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
KIDS-DOC-ON-WHEELS
Practice address
4112 E Ponce de Leon Ave # 2
Clarkston, GA 30021-8106
Phone
(404) 574-2512
Fax
(404) 296-7211
NPI assigned
Jul 11, 2017
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 14, 2017

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

Authorized official

Name
Dr. Lynette R Wilson-Phillips, MDNPI 1992769269
Title
Board of Directors
Phone
(404) 574-2512

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208000000X Primary

Addresses

Primary practice location

4112 E Ponce de Leon Ave # 2
Clarkston, GA 30021-8106

Mailing address

4112 E Ponce de Leon Ave # 2
Clarkston, GA 30021-8106
Phone (404) 574-2512

Other practice location 1

4112 E Ponce De Leon Ave # 2
Clarkston, GA 30021-8106
Phone (404) 574-2512

Other identifiers 1

IdentifierTypeStateIssuer
003193946AMedicaidGA

National Provider Directory

National Provider Directory

Locations

4112 E Ponce de Leon Ave
#2
Clarkston, GA 30021
Phone (404) 574-2512

4112 E Ponce de Leon Ave
Ste 2
Clarkston, GA 30021
Phone (404) 574-2512

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1499731200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1513209600000",
    "number": "1497277404",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4112 E PONCE DE LEON AVE # 2",
            "city": "CLARKSTON",
            "state": "GA",
            "postal_code": "300218106",
            "telephone_number": "404-574-2512",
            "fax_number": "404-296-7211"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4112 E PONCE DE LEON AVE # 2",
            "city": "CLARKSTON",
            "state": "GA",
            "postal_code": "300218106",
            "telephone_number": "404-574-2512",
            "fax_number": "404-296-7211"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "4112 E Ponce De Leon Ave # 2",
            "address_purpose": "LOCATION",
            "city": "Clarkston",
            "state": "GA",
            "postal_code": "300218106",
            "country_code": "US",
            "telephone_number": "404-574-2512",
            "fax_number": "404-296-7211",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "KIDS-DOC-ON-WHEELS",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-07-11",
        "last_updated": "2017-12-14",
        "status": "A",
        "authorized_official_last_name": "WILSON-PHILLIPS",
        "authorized_official_first_name": "LYNETTE",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "BOARD OF DIRECTORS",
        "authorized_official_telephone_number": "404-574-2512",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003193946A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Clarkston, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 14, 2017; 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.