# KALEIDOSCOPE PEDIATRICS PC

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

## Provider details

- **NPI number:** 1407045495
- **Authorized official:** SUSAN GAIL STAVISS MD (PRESIDENT)
- **Authorized official phone:** (770) 509-1234

## Contact information

- **Practice address:** 1523 JOHNSON FERRY RD, SUITE 150, MARIETTA, GA 30062-6438
- **Practice address phone:** (770) 509-1234
- **Mailing address:** 1523 JOHNSON FERRY RD, SUITE 150, MARIETTA, GA 30062-6438
- **Mailing address phone:** (770) 509-1234

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2080A0000X | Pediatric Adolescent Medicine Physician | — | NULL | Yes |
| 2080A0000X | Pediatric Adolescent Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 10/16/2007
- **Last updated:** 10/16/2007