Healthcare Provider Details

I. General information

NPI: 1629125505
Provider Name (Legal Business Name): SYLVESTER PEDIATRICS & ADOLESCENT MEDICINE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 WEST KELLY ST
SYLVESTER GA
31791-5367
US

IV. Provider business mailing address

203 WEST KELLY ST PO BOX 5367
SYLVESTER GA
31791-5367
US

V. Phone/Fax

Practice location:
  • Phone: 9-777-0488
  • Fax: 229-777-0476
Mailing address:
  • Phone: 9-777-0488
  • Fax: 229-777-0476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. GRACE DAVIS
Title or Position: CEO
Credential: M.D., M.P.H.
Phone: 229-777-0488