1629125505 NPI number — SYLVESTER PEDIATRICS & ADOLESCENT MEDICINE, P.C.

Table of content: (NPI 1629125505)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629125505 NPI number — SYLVESTER PEDIATRICS & ADOLESCENT MEDICINE, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SYLVESTER PEDIATRICS & ADOLESCENT MEDICINE, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629125505
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
203 WEST KELLY ST
Provider Second Line Business Mailing Address:
PO BOX 5367
Provider Business Mailing Address City Name:
SYLVESTER
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31791-5367
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
9-777-0488
Provider Business Mailing Address Fax Number:
229-777-0476

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
203 WEST KELLY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYLVESTER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31791-5367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
9-777-0488
Provider Business Practice Location Address Fax Number:
229-777-0476
Provider Enumeration Date:
01/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
GRACE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
229-777-0488

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00085003076G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com