Provider Demographics
NPI:1760680987
Name:SOUTH SUBURBAN PEDIATRICS
Entity Type:Organization
Organization Name:SOUTH SUBURBAN PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-773-7754
Mailing Address - Street 1:101 ADAMS STREET
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169
Mailing Address - Country:US
Mailing Address - Phone:617-773-7754
Mailing Address - Fax:617-328-0957
Practice Address - Street 1:101 ADAMS STREET
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169
Practice Address - Country:US
Practice Address - Phone:617-773-7754
Practice Address - Fax:617-328-0957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA54474208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
667895OtherTUFTS
M17310OtherBCBS
MA9785809Medicaid