1134288848 NPI number — SUNSHINE PEDIATRICS PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134288848 NPI number — SUNSHINE PEDIATRICS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNSHINE PEDIATRICS PC
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:
6
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:
1134288848
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1160 CAPITAL AVE STE 105
Provider Second Line Business Mailing Address:
P O BOX 1379
Provider Business Mailing Address City Name:
WATKINSVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30677-1832
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-769-9410
Provider Business Mailing Address Fax Number:
706-769-9475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1160 CAPITAL AVE
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
WATKINSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30677-1832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-769-9410
Provider Business Practice Location Address Fax Number:
706-769-9475
Provider Enumeration Date:
12/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
QUINN-JACKSON
Authorized Official First Name:
JOAN
Authorized Official Middle Name:
NOVA
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
706-769-9410

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  044236 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 106027 . This is a "PEACHSTATE PROVIDER NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 0005703737 . This is a "AETNA PIN #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 044236 . This is a "GEORGIA MEDICAL LIC NUMBE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 526365270003 . This is a "BCBS PROVIDER ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1578555876 . This is a "DANA J HOGAN MD NPI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 10033203 . This is a "AMERIGROUP COMM CARE PROV" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000096226 . This is a "GHP PROVIDER REF#" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000755961E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 658251501A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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