1467677476 NPI number — PEDIATRIX MEDICAL GROUP

Table of content: MS. JEAN ELIZABETH LEE MSN (NPI 1194748814)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467677476 NPI number — PEDIATRIX MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIX MEDICAL GROUP
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:
1467677476
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:
777 HEMLOCK ST
Provider Second Line Business Mailing Address:
BOX 119
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31207-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-633-1626
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
777 HEMLOCK ST
Provider Second Line Business Practice Location Address:
BOX 119
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31207-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-633-1626
Provider Business Practice Location Address Fax Number:
478-765-4171
Provider Enumeration Date:
04/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILDER
Authorized Official First Name:
TERESA
Authorized Official Middle Name:
G
Authorized Official Title or Position:
NURSE PRACTITIONER
Authorized Official Telephone Number:
478-765-4132

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  R030659 , 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)





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