Provider Demographics
NPI:1679584601
Name:BADIA MEDICAL, LLC
Entity Type:Organization
Organization Name:BADIA MEDICAL, LLC
Other - Org Name:LIFEGUARD PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:G
Authorized Official - Last Name:WARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-922-3074
Mailing Address - Street 1:107 PEACOCK DRIVE
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088
Mailing Address - Country:US
Mailing Address - Phone:478-922-3074
Mailing Address - Fax:478-922-3076
Practice Address - Street 1:107 PEACOCK DRIVE
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088
Practice Address - Country:US
Practice Address - Phone:478-922-3074
Practice Address - Fax:478-922-3076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047353208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000834809Medicaid
GA003171301Medicaid