Provider Demographics
NPI:1457613192
Name:SOUTHEAST GEORGIA PEDIATRICS
Entity Type:Organization
Organization Name:SOUTHEAST GEORGIA PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:WYNN
Authorized Official - Last Name:KALLAY
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:478-737-7653
Mailing Address - Street 1:1701 BOULEVARD SQ STE D
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-8022
Mailing Address - Country:US
Mailing Address - Phone:912-387-0445
Mailing Address - Fax:912-226-3513
Practice Address - Street 1:1701 BOULEVARD SQ STE D
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-8022
Practice Address - Country:US
Practice Address - Phone:912-387-0445
Practice Address - Fax:912-226-3513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-08
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041044261QP2300X
GA018950261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
1780767665OtherNPI
1063595973OtherNPI