Organization
PERFORMANCE PEDIATRICS AND SPORTS MEDICINE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TARA ANN MERRITT M.D. (OWNER PHYSICIAN)
(706) 202-3236
Entity
Organization
Contact information
Practice address
1181 LANGFORD DR, BLDG 200-101, BOGART, GA 30622-2542
(706) 207-6694
Mailing address
1181 LANGFORD DR, BLDG 200-101, BOGART, GA 30622-2542
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
58543
GA
208000000X
Pediatrics Physician
58543
GA
2080S0010X
Pediatric Sports Medicine Physician
Primary
58543
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003125239A
—
GA
05
—
489449582C
—
GA
01
—
58543
STATE MEDICAL LICENSE
GA
Enumeration date
07/26/2012
Last updated
07/26/2012
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