=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154447043
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPECTRUM PEDIATRIC GRP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2007
-----------------------------------------------------
Last Update Date | 05/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3104 CREEKSIDE VILLAGE DR SUITE 504
-----------------------------------------------------
City | KENNESAW
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-966-0778
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3104 CREEKSIDE VILLAGE DR SUITE 504
-----------------------------------------------------
City | KENNESAW
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KOLA OLOGUNJA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 770-966-0778
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 050548
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------