Provider Demographics
NPI:1851676589
Name:DR.SOOS PEDIATRICS, PC
Entity Type:Organization
Organization Name:DR.SOOS PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/CREDENTIALING
Authorized Official - Prefix:MISS
Authorized Official - First Name:MALLORY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-272-0203
Mailing Address - Street 1:102 BOWLING LN
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2502
Mailing Address - Country:US
Mailing Address - Phone:478-272-0203
Mailing Address - Fax:478-272-0223
Practice Address - Street 1:102 BOWLING LN
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2502
Practice Address - Country:US
Practice Address - Phone:478-272-0203
Practice Address - Fax:478-272-0223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-13
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000906529DMedicaid