Provider Demographics
NPI:1477009181
Name:MAMA DOC PEDIATRICS, LLC
Entity Type:Organization
Organization Name:MAMA DOC PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN / PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:LOGAN
Authorized Official - Last Name:PENN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-871-5437
Mailing Address - Street 1:400 EAST GRADY STREET
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458
Mailing Address - Country:US
Mailing Address - Phone:912-871-5437
Mailing Address - Fax:912-623-2037
Practice Address - Street 1:400 EAST GRADY STREET
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458
Practice Address - Country:US
Practice Address - Phone:912-871-5437
Practice Address - Fax:912-623-2037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA67374208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty