Provider Demographics
NPI:1467677476
Name:PEDIATRIX MEDICAL GROUP
Entity type:Organization
Organization Name:PEDIATRIX MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:RNCNNP
Authorized Official - Phone:478-765-4132
Mailing Address - Street 1:777 HEMLOCK ST
Mailing Address - Street 2:BOX 119
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31207-0001
Mailing Address - Country:US
Mailing Address - Phone:478-633-1626
Mailing Address - Fax:
Practice Address - Street 1:777 HEMLOCK ST
Practice Address - Street 2:BOX 119
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31207-0001
Practice Address - Country:US
Practice Address - Phone:478-633-1626
Practice Address - Fax:478-765-4171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR030659282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital