Provider Demographics
NPI:1083394266
Name:PEDIATRIC DIGESTIVE HEALTH AND WELLNESS
Entity Type:Organization
Organization Name:PEDIATRIC DIGESTIVE HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:DERICA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:SAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-340-4330
Mailing Address - Street 1:2730 PEACHTREE INDUSTRIAL BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-8627
Mailing Address - Country:US
Mailing Address - Phone:706-340-4330
Mailing Address - Fax:
Practice Address - Street 1:2730 PEACHTREE INDUSTRIAL BLVD STE 105
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-8627
Practice Address - Country:US
Practice Address - Phone:706-340-4330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Single Specialty