Basic Information
| Provider Information | |||||||||
| NPI: | 1174154421 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN UROGYNECOLOGY AND PELVIC SURGERY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2876 | ||||||||
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| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317762876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298919131 | ||||||||
| FaxNumber: | 2298919079 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 31ST AVE SE | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317686771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2295029788 | ||||||||
| FaxNumber: | 2298901266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2020 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | JORDAN | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2298919131 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VF0040X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Female Pelvic Medicine and Reconstructive Surgery |
No ID Information.