Organization
SPECTRUM PEDIATRIC GRP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KOLA OLOGUNJA MD (PRESIDENT)
(770) 966-0778
Entity
Organization
Contact information
Practice address
3104 CREEKSIDE VILLAGE DR, SUITE 504, KENNESAW, GA 30144
(770) 966-0778
Mailing address
3104 CREEKSIDE VILLAGE DR, SUITE 504, KENNESAW, GA 30144
Taxonomy
Speciality
Code
Description
License number
State
261QM2500X
Medical Specialty Clinic/Center
Primary
050548
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000972408G
—
GA
01
—
855356
BLUE CROSS BLUE SHIELD
GA
Enumeration date
03/22/2007
Last updated
05/19/2008
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