Provider Demographics
NPI:1073885828
Name:MIDDLE GEORGIA PEDIATRICS
Entity type:Organization
Organization Name:MIDDLE GEORGIA PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:SETH
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-741-7371
Mailing Address - Street 1:1508 HARDEMAN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-1471
Mailing Address - Country:US
Mailing Address - Phone:478-741-7371
Mailing Address - Fax:478-741-7372
Practice Address - Street 1:1508 HARDEMAN AVE STE B
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1471
Practice Address - Country:US
Practice Address - Phone:478-741-7371
Practice Address - Fax:478-741-7372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0488462080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000872737BMedicaid
GA000872737BMedicaid