SOUTHEAST GEORGIA PEDIATRICS NPI 1457613192

NPI Information

SOUTHEAST GEORGIA PEDIATRICS is a primary care clinic center in Waycross, GA. SOUTHEAST GEORGIA PEDIATRICS NPI is 1457613192. The provider is registered as an organization entity type.

The provider's business location address is:

1701 BOULEVARD SQ STE D
WAYCROSS, GA
ZIP 31501-022
Phone: (912) 387-0445
Fax: (912) 226-3513

The provider's authorized official is Eugene Wynn Kallay .
The authorized official title is Owner and has the following contact phone number (478) 737-7653.

The CLIA number assigned to this NPI record is 11D2180730 - other - wound care clinic with a certificate type of Certificate of Waiver.

The enumeration date for this NPI number is 6/8/2012 and was last updated on 6/15/2020.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

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