Healthcare Provider Details

I. General information

NPI: 1487886123
Provider Name (Legal Business Name): SUWANEE PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2009
Last Update Date: 02/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 LAWRENCEVILLE SUWANEE RD
LAWRENCEVILLE GA
30043-5425
US

IV. Provider business mailing address

1155 LAWRENCEVILLE SUWANEE RD
LAWRENCEVILLE GA
30043-5425
US

V. Phone/Fax

Practice location:
  • Phone: 678-442-0205
  • Fax: 678-442-0185
Mailing address:
  • Phone: 678-442-0205
  • Fax: 678-442-0185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number042380
License Number StateGA

VIII. Authorized Official

Name: DR. BOLAJI T ODUSINA
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 678-442-0205