Healthcare Provider Details

I. General information

NPI: 1396497285
Provider Name (Legal Business Name): SUMTER PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2022
Last Update Date: 01/21/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 GA HIGHWAY 27 E
AMERICUS GA
31709-5249
US

IV. Provider business mailing address

PO BOX 288
AMERICUS GA
31709-0288
US

V. Phone/Fax

Practice location:
  • Phone: 229-924-8082
  • Fax:
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

VIII. Authorized Official

Name: NELSON MADRAZO
Title or Position: MANAGING MEMBER
Credential:
Phone: 229-924-8082