# SPECTRUM PEDIATRIC GRP

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1154447043
- **Authorized official:** KOLA OLOGUNJA MD (PRESIDENT)
- **Authorized official phone:** (770) 966-0778

## Contact information

- **Practice address:** 3104 CREEKSIDE VILLAGE DR, SUITE 504, KENNESAW, GA 30144
- **Practice address phone:** (770) 966-0778
- **Mailing address:** 3104 CREEKSIDE VILLAGE DR, SUITE 504, KENNESAW, GA 30144

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QM2500X | Medical Specialty Clinic/Center | 050548 | GA | Yes |

## Other

- **Enumeration date:** 03/22/2007
- **Last updated:** 05/19/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 000972408G | — | GA |
| 01 | — | 855356 | BLUE CROSS BLUE SHIELD | GA |