Provider Demographics
NPI:1629356670
Name:PEDIATRIC PULMONOLOGY OF CENTRAL GA
Entity Type:Organization
Organization Name:PEDIATRIC PULMONOLOGY OF CENTRAL GA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MGR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:R
Authorized Official - Last Name:COBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-755-0036
Mailing Address - Street 1:1062 FORSYTH ST
Mailing Address - Street 2:SUITE 2 C
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-8637
Mailing Address - Country:US
Mailing Address - Phone:478-755-0036
Mailing Address - Fax:478-755-1254
Practice Address - Street 1:1062 FORSYTH ST
Practice Address - Street 2:SUITE 2 C
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-8637
Practice Address - Country:US
Practice Address - Phone:478-755-0036
Practice Address - Fax:478-755-1254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-25
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000670535JMedicaid
319745OtherWELLCARE