Provider Demographics
NPI:1295999795
Name:EAST GEORGIA PEDIATRICS
Entity type:Organization
Organization Name:EAST GEORGIA PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DEAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-489-3325
Mailing Address - Street 1:127 N COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-5387
Mailing Address - Country:US
Mailing Address - Phone:912-489-3325
Mailing Address - Fax:912-764-4977
Practice Address - Street 1:715 NORTHSIDE DR E
Practice Address - Street 2:SUITE 5 PMB 398
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-4712
Practice Address - Country:US
Practice Address - Phone:912-489-3325
Practice Address - Fax:912-764-4977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-14
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10051619OtherAMERIGROUP
GA000372391GMedicaid
GA354428OtherWELLCARE