Provider Demographics
NPI:1215483128
Name:PEDS HEALTH
Entity type:Organization
Organization Name:PEDS HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIANN
Authorized Official - Prefix:
Authorized Official - First Name:ERICKA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL-PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-777-5490
Mailing Address - Street 1:5710 OGEECHEE RD
Mailing Address - Street 2:STE 200 BOX 283
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-9515
Mailing Address - Country:US
Mailing Address - Phone:912-777-5490
Mailing Address - Fax:912-777-5471
Practice Address - Street 1:3710 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6209
Practice Address - Country:US
Practice Address - Phone:921-777-5490
Practice Address - Fax:912-777-5491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047258261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service