Provider Demographics
NPI:1083878920
Name:COSSIO PEDIATRICS LLC
Entity Type:Organization
Organization Name:COSSIO PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:FITTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-354-3130
Mailing Address - Street 1:334 STEPHENSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5929
Mailing Address - Country:US
Mailing Address - Phone:912-354-3130
Mailing Address - Fax:912-354-5860
Practice Address - Street 1:334 STEPHENSON AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5929
Practice Address - Country:US
Practice Address - Phone:912-354-3130
Practice Address - Fax:912-354-5860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036357174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000872638AMedicaid
GA1861423295OtherINDIDIVUAL NATIONAL PROVIDER #
GA000874244AMedicaid
GA1912938366OtherINDIVIDUAL NATIONAL PROVIDER #
GA000532727AMedicaid
GA1811922693OtherINDIVIDUAL NATIONAL PROVIDER #