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General NPI Number Information
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NPI Number | 1083394266
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DIGESTIVE HEALTH AND WELLNESS
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Dates
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Enumeration Date | 07/21/2023
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Last Update Date | 09/04/2024
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Provider Practice Location Address
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Address Line | 3925 HARRISON RD STE 100
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City | LOGANVILLE
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State | GA
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Zip | 30052-5898
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Country | US
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Telephone | 706-340-4330
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Fax |
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Provider Business Mailing Address
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Address Line | 3925 HARRISON RD STE 100
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City | LOGANVILLE
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State | GA
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Zip | 30052-5898
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Country | US
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Telephone | 706-340-4330
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Fax |
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Authorized Official
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Title or Position | OWNER/ AUTHORIZED OFFICIAL
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Name | DR. DERICA NICOLE SAMS
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Credential | MD
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Telephone | 706-340-4330
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080P0206X
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Taxonomy Name | Pediatric Gastroenterology Physician
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License Number |
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License Number State |
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