Provider Demographics
NPI:1275121758
Name:INFINITY PEDIATRIC AND ADOLESCENT MEDICINE LLC
Entity Type:Organization
Organization Name:INFINITY PEDIATRIC AND ADOLESCENT MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:S
Authorized Official - Last Name:BAUCOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-780-8400
Mailing Address - Street 1:109 SLEEPY RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-1357
Mailing Address - Country:US
Mailing Address - Phone:757-537-1064
Mailing Address - Fax:
Practice Address - Street 1:1809 S CHURCH ST STE 302
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:VA
Practice Address - Zip Code:23430-1861
Practice Address - Country:US
Practice Address - Phone:757-780-8400
Practice Address - Fax:757-432-3279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-09
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty