South Boston Pediatrics, PC

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

0101232220 Issued in VA

Legal business name

SOUTH BOSTON PEDIATRICS, PC

Practice address

2202 Beechmont Rd
South Boston, VA 24592-1614

Phone

(434) 572-3635

NPI assigned

Sep 5, 2012

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Nonna Lyn Ebalo, M.D.

Title

President

Phone

(434) 470-3489

Specialties & licenses 1

Addresses

Other identifiers 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Nonna Lyn M Ebalo, MD

  • Pediatrics Physician
  • South Boston, VA
  • NPI 1861472524
  NPD (past)
• Amy C Mills, FNP

  • Family Nurse Practitioner
  • South Boston, VA
  • NPI 1538658703
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1346803200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1346803200000",
    "number": "1356690366",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 774",
            "city": "SOUTH BOSTON",
            "state": "VA",
            "postal_code": "245920774",
            "telephone_number": "434-572-3635"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2202 BEECHMONT RD",
            "city": "SOUTH BOSTON",
            "state": "VA",
            "postal_code": "245921614",
            "telephone_number": "434-572-3635"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH BOSTON PEDIATRICS, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-09-05",
        "last_updated": "2012-09-05",
        "status": "A",
        "authorized_official_last_name": "EBALO",
        "authorized_official_first_name": "NONNA",
        "authorized_official_middle_name": "LYN",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "434-470-3489",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics",
            "state": "VA",
            "license": "0101232220",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "01046086",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Minkyeong Son, DDS
• Soul Guided Healing Wellness LLC
• South Boston Behavioral Health LLC
• South Boston Health & Rehab Center, LLC
• South Boston Manor, LLC
• South Boston Transportation LLC
• Southern Gastroenterology Associates PC
• Southern Gastroenterology Endoscopy Center, P.C.
• Southside Behavioral Health - Brandon Home
• Southside Emergency Physicians PC

• Pediatrics Physician in South Boston, VA
• Providers in South Boston, VA by specialty
• Pediatrics Physician in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 5, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.