Provider Demographics
NPI:1144400664
Name:SUMTER PEDIATRICS LLC
Entity Type:Organization
Organization Name:SUMTER PEDIATRICS LLC
Other - Org Name:SUMTER PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:T
Authorized Official - Last Name:MADRAZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-924-8082
Mailing Address - Street 1:151 GA HIGHWAY 27 E
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-5249
Mailing Address - Country:US
Mailing Address - Phone:229-924-8082
Mailing Address - Fax:
Practice Address - Street 1:151 GA HIGHWAY 27 E
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-5249
Practice Address - Country:US
Practice Address - Phone:229-924-8082
Practice Address - Fax:229-924-8009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X, 363LF0000X, 363LF0000X
GA004223363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA219934685AMedicaid