Provider Demographics
NPI:1932288271
Name:MITCHELL COUNTY PEDIATRICS CENTER
Entity Type:Organization
Organization Name:MITCHELL COUNTY PEDIATRICS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BASHIRU
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAWODU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-336-9769
Mailing Address - Street 1:35 S SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:CAMILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31730-1705
Mailing Address - Country:US
Mailing Address - Phone:229-336-9769
Mailing Address - Fax:229-336-3867
Practice Address - Street 1:35 S SCOTT ST
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-1705
Practice Address - Country:US
Practice Address - Phone:229-336-9769
Practice Address - Fax:229-336-3867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052162208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA341793Medicaid
GA340537Medicaid