Basic Information
| Provider Information | |||||||||
| NPI: | 1174917124 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHLAND CONSOLIDATED EMERGENCY SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 S MADISON ST | ||||||||
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| City: | THOMASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317925473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2922360831 | ||||||||
| FaxNumber: | 2292360871 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | ELBERTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306351897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062833151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2015 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | FLETCHER | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2292360831 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 9999999 | 05 | GA | MEDICAID |