Provider Demographics
NPI:1831210657
Name:PEDIATRICS OF GLYNN ON THE ISLAND
Entity type:Organization
Organization Name:PEDIATRICS OF GLYNN ON THE ISLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:C
Authorized Official - Last Name:LUMPKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-634-2795
Mailing Address - Street 1:172 FOLLINS LN
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-4268
Mailing Address - Country:US
Mailing Address - Phone:912-634-2795
Mailing Address - Fax:912-638-5636
Practice Address - Street 1:172 FOLLINS LN
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-4268
Practice Address - Country:US
Practice Address - Phone:912-634-2795
Practice Address - Fax:912-638-5636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10065447OtherLEE HEERY AMERIGROUP
GA963103OtherFRANCES OWEN BCBS #
GA10066660OtherCAROLE LYONS AMERIGROUP #
GA335886OtherCAROLE LYONS WELLCARE#
GA1699873299OtherLEE HEERY NPI#
GA00672977BMedicaid
GA969118OtherLEE HEERY BCBS GA #
GA00760966BMedicaid
GA12545338912OtherCAROLE LYONS NPI
GA365007OtherLEE HEERY WELLCARE #
GA10066698OtherOWEN AMERIGROUP#
GA335898OtherOWEN WELLCARE#
GA=========OtherFRANCES OWEN TAX ID
GA=========OtherLEE HEERY TAX ID#