Basic Information
| Provider Information | |||||||||
| NPI: | 1194985093 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VIDALIA PULMONOLOGY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 407 | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304750407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125388105 | ||||||||
| FaxNumber: | 9125388109 | ||||||||
| Practice Location | |||||||||
| Address1: | 1811 EDWINA DR | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304748963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125388105 | ||||||||
| FaxNumber: | 9125388109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2008 | ||||||||
| LastUpdateDate: | 05/29/2014 | ||||||||
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| AuthorizedOfficialLastName: | O'STEEN | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9125385314 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHEAST REGIONAL PRIMARY CARE CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RS0012X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RP1001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.