Provider Demographics
NPI:1639558877
Name:RAINBOW PEDIATRICS ASSOCIATES PC
Entity Type:Organization
Organization Name:RAINBOW PEDIATRICS ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:DANELL
Authorized Official - Last Name:GLOVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-403-2046
Mailing Address - Street 1:16 HOSPITAL PARK
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-6700
Mailing Address - Country:US
Mailing Address - Phone:229-228-0617
Mailing Address - Fax:
Practice Address - Street 1:16 HOSPITAL PARK
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6700
Practice Address - Country:US
Practice Address - Phone:229-228-0617
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034750208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003155912AMedicaid