Provider Demographics
NPI:1477638575
Name:PRIMARY PEDIATRICS, PC
Entity type:Organization
Organization Name:PRIMARY PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:SLADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-741-3007
Mailing Address - Street 1:5300 BOWMAN RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210
Mailing Address - Country:US
Mailing Address - Phone:478-741-3007
Mailing Address - Fax:478-200-1960
Practice Address - Street 1:5300 BOWMAN RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210
Practice Address - Country:US
Practice Address - Phone:478-741-3007
Practice Address - Fax:478-200-1960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300034047AMedicaid
GA003216177AMedicaid