Provider Demographics
NPI:1629125505
Name:SYLVESTER PEDIATRICS & ADOLESCENT MEDICINE, P.C.
Entity Type:Organization
Organization Name:SYLVESTER PEDIATRICS & ADOLESCENT MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:229-777-0488
Mailing Address - Street 1:203 WEST KELLY ST
Mailing Address - Street 2:PO BOX 5367
Mailing Address - City:SYLVESTER
Mailing Address - State:GA
Mailing Address - Zip Code:31791-5367
Mailing Address - Country:US
Mailing Address - Phone:009-777-0488
Mailing Address - Fax:229-777-0476
Practice Address - Street 1:203 WEST KELLY ST
Practice Address - Street 2:
Practice Address - City:SYLVESTER
Practice Address - State:GA
Practice Address - Zip Code:31791-5367
Practice Address - Country:US
Practice Address - Phone:009-777-0488
Practice Address - Fax:229-777-0476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00085003076GMedicaid