Jamie F Wallace – Pediatrics Physician

Key facts

NPI: 1205883147
Entity type: Individual (NPI type 1)
Primary specialty: Pediatrics Physician 208000000X
License: 043044 (GA)
Practice address: 735 Glynn St S
Fayetteville, GA 30214-2049
Phone: (770) 461-4126
Fax: (770) 461-8852
NPI assigned: May 27, 2006
Sex: Female
Sole proprietor: No

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Abc Pediatrics Pediatrics Physician · Fayetteville, GA · NPI 1902923964

NPD (past) PEDIATRICS

Medicare participation

Medicare fee-for-service enrollment: Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD): No
Credentials: Doctor of Medicine

State licenses

License	State	Type	Specialty
043044	GA	MD	Pediatrics Physician

Practice roles

Organization	Specialty	Status	New patients
Abc Pediatrics	Pediatrics	Past	Accepting new patients

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Pediatrics Physician	208000000X	043044	GA	Yes

Addresses

Primary practice location

735 Glynn St S
Fayetteville, GA 30214-2049

Mailing address

735 Glynn St S
Fayetteville, GA 30214-2049
Phone (770) 461-4126

Other identifiers

Identifier	Type	State	Issuer
00794483A	Medicaid	GA

Other names

Jamie M Flanders Former name

Other providers in Fayetteville, GA

All providers in Fayetteville, GA · Pediatrics Physician in Georgia

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 8, 2007. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.