Provider Demographics
NPI:1457649774
Name:SOUTHWEST GEORGIA PEDIATRICS
Entity Type:Organization
Organization Name:SOUTHWEST GEORGIA PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-888-8121
Mailing Address - Street 1:1110 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1949
Mailing Address - Country:US
Mailing Address - Phone:229-888-8121
Mailing Address - Fax:229-888-6374
Practice Address - Street 1:1110 N MONROE ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1949
Practice Address - Country:US
Practice Address - Phone:229-888-8121
Practice Address - Fax:229-888-6374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty