Healthcare Provider Details

I. General information

NPI: 1497082242
Provider Name (Legal Business Name): AFFINITY PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2009
Last Update Date: 11/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 US HIGHWAY 41 N
TIFTON GA
31794-2749
US

IV. Provider business mailing address

2225 US HIGHWAY 41 N
TIFTON GA
31794-2749
US

V. Phone/Fax

Practice location:
  • Phone: 229-391-4100
  • Fax:
Mailing address:
  • Phone: 229-391-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number049525
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number049525
License Number StateGA

VIII. Authorized Official

Name: BECKY WILKERSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 229-391-4100