NPIMap

Organization Active NPI

Southeast Georgia Pediatrics

  • Primary Care Clinic/Center
  • Waycross, GA
National Provider Identifier
1457613192
Registry record updated Jun 15, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
License
018950 Issued in GA
Legal business name
SOUTHEAST GEORGIA PEDIATRICS
Practice address
1701 Boulevard SQ Ste D
Waycross, GA 31501-8022
Phone
(912) 387-0445
Fax
(912) 226-3513
NPI assigned
Jun 8, 2012
Last updated
Jun 15, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 15, 2020

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

Authorized official

Name
Dr. Eugene Wynn Kallay II, M.D.NPI 1063595973
Title
Owner
Phone
(478) 737-7653

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X 041044 GA
Primary Care Clinic/Center 261QP2300X 018950 GA Primary

Addresses

Primary practice location

1701 Boulevard SQ Ste D
Waycross, GA 31501-8022

Mailing address

1701 Boulevard SQ Ste D
Waycross, GA 31501-8022
Phone (912) 387-0445

Other identifiers 2

IdentifierTypeStateIssuer
1063595973OtherNPI
1780767665OtherNPI

National Provider Directory

National Provider Directory

Locations

1701 Boulevard Sq
Ste D
Waycross, GA 31501
Phone (912) 387-0445

Interoperability endpoints

  • FHIR API: https://fhir4.healow.com/fhir/r4/BICIBA

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1339113600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1592179200000",
    "number": "1457613192",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1701 BOULEVARD SQ STE D",
            "city": "WAYCROSS",
            "state": "GA",
            "postal_code": "315018022",
            "telephone_number": "912-387-0445",
            "fax_number": "912-226-3513"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1701 BOULEVARD SQ STE D",
            "city": "WAYCROSS",
            "state": "GA",
            "postal_code": "315018022",
            "telephone_number": "912-387-0445",
            "fax_number": "912-226-3513"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEAST GEORGIA PEDIATRICS",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-06-08",
        "last_updated": "2020-06-15",
        "certification_date": "2020-06-15",
        "status": "A",
        "authorized_official_last_name": "KALLAY",
        "authorized_official_first_name": "EUGENE",
        "authorized_official_middle_name": "WYNN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "478-737-7653",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_name_suffix": "II",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "GA",
            "license": "041044",
            "primary": false
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "GA",
            "license": "018950",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI",
            "identifier": "1063595973",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI",
            "identifier": "1780767665",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Waycross, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 15, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.