Provider Demographics
NPI:1679766299
Name:MOULTRIE PEDIATRICS, LLC
Entity Type:Organization
Organization Name:MOULTRIE PEDIATRICS, LLC
Other - Org Name:CHILDREN'S MEDICAL GROUP OF SW GA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARION
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-985-1293
Mailing Address - Street 1:PO BOX 129
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-0129
Mailing Address - Country:US
Mailing Address - Phone:229-985-1293
Mailing Address - Fax:229-891-2123
Practice Address - Street 1:1 SWEET BAY CT
Practice Address - Street 2:SUITE A
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6756
Practice Address - Country:US
Practice Address - Phone:229-985-1293
Practice Address - Fax:229-891-2123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA3083OtherPEACHSTATE
GA396284OtherWELLCARE
GA300035718AMedicaid