Basic Information
| Provider Information | |||||||||
| NPI: | 1396497285 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUMTER PEDIATRICS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 288 | ||||||||
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| City: | AMERICUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317090288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299248082 | ||||||||
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| Practice Location | |||||||||
| Address1: | 151 GA HIGHWAY 27 E | ||||||||
| Address2: | |||||||||
| City: | AMERICUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317095249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299248082 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2022 | ||||||||
| LastUpdateDate: | 01/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | MADRAZO | ||||||||
| AuthorizedOfficialFirstName: | NELSON | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2299248082 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUMTER PEDIATRICS LLC | ||||||||
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| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.