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General NPI Number Information
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NPI Number | 1477009181
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Entity Type | Organization
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Legal Business Name | MAMA DOC PEDIATRICS, LLC
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Dates
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Enumeration Date | 09/01/2016
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Last Update Date | 09/01/2016
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Provider Practice Location Address
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Address Line | 400 EAST GRADY STREET
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City | STATESBORO
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State | GA
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Zip | 30458
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Country | US
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Telephone | 912-871-5437
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Fax | 912-623-2037
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Provider Business Mailing Address
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Address Line | 400 EAST GRADY STREET
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City | STATESBORO
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State | GA
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Zip | 30458
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Country | US
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Telephone | 912-871-5437
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Fax | 912-623-2037
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Authorized Official
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Title or Position | PHYSICIAN / PRESIDENT
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Name | DR. ELIZABETH LOGAN PENN
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Credential | M.D.
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Telephone | 912-871-5437
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 67374
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License Number State | GA
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