Provider Demographics
NPI:1720341514
Name:BULLOCH PEDIATRICS GROUP, LLC
Entity Type:Organization
Organization Name:BULLOCH PEDIATRICS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:MHSA
Authorized Official - Phone:912-871-4847
Mailing Address - Street 1:1497 FAIR RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0822
Mailing Address - Country:US
Mailing Address - Phone:912-871-4847
Mailing Address - Fax:912-871-5562
Practice Address - Street 1:1497 FAIR RD
Practice Address - Street 2:SUITE 200
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0822
Practice Address - Country:US
Practice Address - Phone:912-871-4847
Practice Address - Fax:912-871-5562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN104429363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty