NPIMap

Organization Active NPI

Suwanee Pediatrics PC

  • Primary Care Clinic/Center
  • Lawrenceville, GA
National Provider Identifier
1487886123
Registry record updated Feb 25, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
License
042380 Issued in GA
Legal business name
SUWANEE PEDIATRICS PC
Practice address
1155 Lawrenceville Suwanee Rd
Lawrenceville, GA 30043-5425
Phone
(678) 442-0205
Fax
(678) 442-0185
NPI assigned
Aug 13, 2009
Last updated
Feb 25, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 25, 2011

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

Authorized official

Name
Dr. Bolaji T Odusina, M.D.NPI 1306803762
Title
Medical Director
Phone
(678) 442-0205

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Clinic/Center 261QP2300X 042380 GA Primary

Addresses

Primary practice location

1155 Lawrenceville Suwanee Rd
Lawrenceville, GA 30043-5425

Mailing address

1155 Lawrenceville Suwanee Rd
Lawrenceville, GA 30043-5425
Phone (678) 442-0205

Other identifiers 2

IdentifierTypeStateIssuer
647974880BMedicaidGA
000757567BMedicaidGA

Laboratory certificates & supplier records

Derived by NPIMap

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
11D0966273Suwanee Pediatrics LLC1155 Lawrenceville-Suwanee Road, Lawrenceville, GA 30043Certificate of waiverOct 11, 2027

National Provider Directory

National Provider Directory

Locations

1155 Lawrenceville Suwanee Rd
Lawrenceville, GA 30043
Phone (678) 422-0205

Practitioners & affiliated clinicians

Practitioners 5

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": "1250121600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1298592000000",
    "number": "1487886123",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1155 LAWRENCEVILLE SUWANEE RD",
            "city": "LAWRENCEVILLE",
            "state": "GA",
            "postal_code": "300435425",
            "telephone_number": "678-442-0205",
            "fax_number": "678-442-0185"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1155 LAWRENCEVILLE SUWANEE RD",
            "city": "LAWRENCEVILLE",
            "state": "GA",
            "postal_code": "300435425",
            "telephone_number": "678-442-0205",
            "fax_number": "678-442-0185"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SUWANEE PEDIATRICS PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-08-13",
        "last_updated": "2011-02-25",
        "status": "A",
        "authorized_official_last_name": "ODUSINA",
        "authorized_official_first_name": "BOLAJI",
        "authorized_official_middle_name": "T",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "678-442-0205",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": "GA",
            "license": "042380",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "647974880B",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000757567B",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Lawrenceville, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 25, 2011; 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.