1831210657 NPI number — PEDIATRICS OF GLYNN ON THE ISLAND

Table of content: (NPI 1831210657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831210657 NPI number — PEDIATRICS OF GLYNN ON THE ISLAND

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRICS OF GLYNN ON THE ISLAND
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:
1831210657
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:
172 FOLLINS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST SIMONS ISLAND
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31522-4268
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-634-2795
Provider Business Mailing Address Fax Number:
912-638-5636

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
172 FOLLINS LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST SIMONS ISLAND
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31522-4268
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-634-2795
Provider Business Practice Location Address Fax Number:
912-638-5636
Provider Enumeration Date:
04/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LUMPKIN
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
912-634-2795

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: 10065447 . This is a "LEE HEERY AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 963103 . This is a "FRANCES OWEN BCBS #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 10066660 . This is a "CAROLE LYONS AMERIGROUP #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 335886 . This is a "CAROLE LYONS WELLCARE#" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1699873299 . This is a "LEE HEERY NPI#" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00672977B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 969118 . This is a "LEE HEERY BCBS GA #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00760966B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 12545338912 . This is a "CAROLE LYONS NPI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 365007 . This is a "LEE HEERY WELLCARE #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 10066698 . This is a "OWEN AMERIGROUP#" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 335898 . This is a "OWEN WELLCARE#" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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