Provider Demographics
NPI:1588825277
Name:SIERRA MEDICAL SERVICES, LLC
Entity Type:Organization
Organization Name:SIERRA MEDICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:DE LASIERRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-610-8620
Mailing Address - Street 1:P.O. BOX 28170
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31221-8170
Mailing Address - Country:US
Mailing Address - Phone:478-254-5943
Mailing Address - Fax:478-254-6093
Practice Address - Street 1:528 SOUTH 8TH STREET
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224
Practice Address - Country:US
Practice Address - Phone:770-467-1224
Practice Address - Fax:770-467-1225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056820207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA382655211FMedicaid
DP1571OtherRAILROAD MEDICARE
GA511G701053Medicare Oscar/Certification