Provider Demographics
NPI:1477620912
Name:MOULTRIE CENTER FOR ADULT AND PEDIATRIC HEALTHCARE, PC
Entity Type:Organization
Organization Name:MOULTRIE CENTER FOR ADULT AND PEDIATRIC HEALTHCARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-985-6700
Mailing Address - Street 1:760 26TH AVE., SE
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-6799
Mailing Address - Country:US
Mailing Address - Phone:229-985-6700
Mailing Address - Fax:229-891-2382
Practice Address - Street 1:760 26TH AVE SE
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6799
Practice Address - Country:US
Practice Address - Phone:229-985-6700
Practice Address - Fax:229-891-2382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4399Medicare ID - Type Unspecified