Healthcare Provider Details

I. General information

NPI: 1144400664
Provider Name (Legal Business Name): SUMTER PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 GA HIGHWAY 27 E
AMERICUS GA
31709-5249
US

IV. Provider business mailing address

151 GA HIGHWAY 27 E
AMERICUS GA
31709-5249
US

V. Phone/Fax

Practice location:
  • Phone: 229-924-8082
  • Fax: 229-924-8009
Mailing address:
  • Phone: 229-924-8082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004223
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. NELSON T MADRAZO
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 229-924-8082