# PERFORMANCE PEDIATRICS AND SPORTS MEDICINE, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1295081321
- **Authorized official:** DR. TARA ANN MERRITT M.D. (OWNER PHYSICIAN)
- **Authorized official phone:** (706) 202-3236

## Contact information

- **Practice address:** 1181 LANGFORD DR, BLDG 200-101, BOGART, GA 30622-2542
- **Practice address phone:** (706) 207-6694
- **Mailing address:** 1181 LANGFORD DR, BLDG 200-101, BOGART, GA 30622-2542

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207R00000X | Internal Medicine Physician | 58543 | GA | — |
| 208000000X | Pediatrics Physician | 58543 | GA | — |
| 2080S0010X | Pediatric Sports Medicine Physician | 58543 | GA | Yes |

## Other

- **Enumeration date:** 07/26/2012
- **Last updated:** 07/26/2012