Basic Information
| Provider Information | |||||||||
| NPI: | 1144400664 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMTER PEDIATRICS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUMTER PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 GA HIGHWAY 27 E | ||||||||
| Address2: | |||||||||
| City: | AMERICUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317095249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299248082 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 151 GA HIGHWAY 27 E | ||||||||
| Address2: | |||||||||
| City: | AMERICUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317095249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299248082 | ||||||||
| FaxNumber: | 2299248009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2007 | ||||||||
| LastUpdateDate: | 01/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MADRAZO | ||||||||
| AuthorizedOfficialFirstName: | NELSON | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2299248082 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 004223 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 219934685A | 05 | GA | MEDICAID |