Basic Information
Provider Information | |||||||||
NPI: | 1114998507 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COURSEY | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | W | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 14459 | ||||||||
Address2: |   | ||||||||
City: | SAVANNAH | ||||||||
State: | GA | ||||||||
PostalCode: | 314161459 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9127904000 | ||||||||
FaxNumber: | 9127904407 | ||||||||
Practice Location | |||||||||
Address1: | 230 E DERENNE AVE | ||||||||
Address2: |   | ||||||||
City: | SAVANNAH | ||||||||
State: | GA | ||||||||
PostalCode: | 314056736 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9127904000 | ||||||||
FaxNumber: | 9127904407 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/01/2006 | ||||||||
LastUpdateDate: | 01/21/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 059056 | GA | Y |   | Allopathic & Osteopathic Physicians | Urology |   | 208800000X | 30558 | SC | N |   | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 003100762J | 05 | GA |   | MEDICAID | 3723229 | 05 | TN |   | MEDICAID |