Provider Demographics
NPI:1154447043
Name:SPECTRUM PEDIATRIC GRP
Entity type:Organization
Organization Name:SPECTRUM PEDIATRIC GRP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:OLOGUNJA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-966-0778
Mailing Address - Street 1:3104 CREEKSIDE VILLAGE DR
Mailing Address - Street 2:SUITE 504
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3104 CREEKSIDE VILLAGE DR
Practice Address - Street 2:SUITE 504
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144
Practice Address - Country:US
Practice Address - Phone:770-966-0778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050548261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA855356OtherBLUE CROSS BLUE SHIELD
GA000972408GMedicaid