Provider Demographics
NPI:1154793214
Name:COLQUITT REGIONAL PEDIATRICS, LLC
Entity type:Organization
Organization Name:COLQUITT REGIONAL PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMANOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-891-9559
Mailing Address - Street 1:PO BOX 1120
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-1120
Mailing Address - Country:US
Mailing Address - Phone:229-985-5437
Mailing Address - Fax:
Practice Address - Street 1:1 SWEET BAY CT
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6756
Practice Address - Country:US
Practice Address - Phone:229-985-5437
Practice Address - Fax:229-985-0131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-28
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003170656BMedicaid
GA003170656AMedicaid
GA10270G0891OtherMEDICARE GROUP PTAN