Basic Information
| Provider Information | |||||||||
| NPI: | 1104083252 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEART OF GEORGIA SURGERY ASSOCIATES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEART OF GEORGIA SURGERY ASSOCIATES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 937 | ||||||||
| Address2: | |||||||||
| City: | EASTMAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310230937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4783747762 | ||||||||
| FaxNumber: | 4783741177 | ||||||||
| Practice Location | |||||||||
| Address1: | 1085 PLAZA AVE | ||||||||
| Address2: | |||||||||
| City: | EASTMAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310239102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4783747762 | ||||||||
| FaxNumber: | 4783741177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2008 | ||||||||
| LastUpdateDate: | 06/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | HESTER | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DODGE COUNTY HOSPITAL CFO | ||||||||
| AuthorizedOfficialTelephone: | 4784484050 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.