Basic Information
| Provider Information | |||||||||
| NPI: | 1124093588 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UROLOGY SURGERY CENTER OF SAVANNAH, LLLP | ||||||||
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| OtherOrganizationName: | UROLOGY SURGERY CENTER, LLP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13427 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314160427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127904068 | ||||||||
| FaxNumber: | 9127904407 | ||||||||
| Practice Location | |||||||||
| Address1: | 230 E DERENNE AVE | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314056736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127904068 | ||||||||
| FaxNumber: | 9127904407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 04/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | SHAW | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
| AuthorizedOfficialMiddleName: | ELAINE | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9127904000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 025276 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 916212415A | 05 | GA | MEDICAID | ASC062 | 05 | SC | MEDICAID |