=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104938703
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOLDEN ISLES PEDIATRICS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 01/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1919 GLYNN AVE SUITE 60
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31520-6176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-265-4843
-----------------------------------------------------
Fax | 912-265-4869
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1919 GLYNN AVE SUITE 60
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31520-6176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-265-4843
-----------------------------------------------------
Fax | 912-265-4869
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. HEATHER A SVENSON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 912-265-4843
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 050841
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------