Provider Demographics
NPI:1720376999
Name:HAZLEHURST PEDIATRICS, PC
Entity Type:Organization
Organization Name:HAZLEHURST PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:HIGHBAUGH-BATTLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-375-3360
Mailing Address - Street 1:PO BOX 630
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:GA
Mailing Address - Zip Code:31539-0630
Mailing Address - Country:US
Mailing Address - Phone:912-375-3360
Mailing Address - Fax:912-375-3365
Practice Address - Street 1:143 S TALLAHASSEE ST
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:GA
Practice Address - Zip Code:31539-6466
Practice Address - Country:US
Practice Address - Phone:912-375-3360
Practice Address - Fax:912-375-3365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA59076208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA779621656AMedicaid