Provider Demographics
NPI:1336411347
Name:JEFFERSON PEDIATRICS, INC.
Entity Type:Organization
Organization Name:JEFFERSON PEDIATRICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-367-1010
Mailing Address - Street 1:2610 HIGHWAY 129 N
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:GA
Mailing Address - Zip Code:30549-2652
Mailing Address - Country:US
Mailing Address - Phone:706-367-1010
Mailing Address - Fax:
Practice Address - Street 1:2610 HIGHWAY 129 N
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:GA
Practice Address - Zip Code:30549-2652
Practice Address - Country:US
Practice Address - Phone:706-367-1010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038372261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10055116OtherAMERIGROUP
GA309153OtherWELLCARE
GA00608253HMedicaid