Provider Demographics
NPI:1356690366
Name:SOUTH BOSTON PEDIATRICS, PC
Entity Type:Organization
Organization Name:SOUTH BOSTON PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NONNA
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:EBALO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-470-3489
Mailing Address - Street 1:PO BOX 774
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-0774
Mailing Address - Country:US
Mailing Address - Phone:434-572-3635
Mailing Address - Fax:
Practice Address - Street 1:2202 BEECHMONT RD
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1614
Practice Address - Country:US
Practice Address - Phone:434-572-3635
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232220208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA01046086Medicaid
VA01046086Medicaid