Healthcare Provider Details

I. General information

NPI: 1679775712
Provider Name (Legal Business Name): BULLOCH PEDIATRICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1497 FAIR RD STE 200
STATESBORO GA
30458-0822
US

IV. Provider business mailing address

1497 FAIR RD STE 200
STATESBORO GA
30458-0822
US

V. Phone/Fax

Practice location:
  • Phone: 912-871-4847
  • Fax: 912-871-5562
Mailing address:
  • Phone: 912-871-4847
  • Fax: 912-871-5562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MELODY K LIGHTSEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 912-871-4847