Basic Information
| Provider Information | |||||||||
| NPI: | 1215574926 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWELL AMBULATORY INC | ||||||||
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| OtherOrganizationName: | SOUTHWELL LOWNDES ENDOSCOPY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 907 E 18TH STREET | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | TILTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317943684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293533422 | ||||||||
| FaxNumber: | 2293536060 | ||||||||
| Practice Location | |||||||||
| Address1: | 3790 OLD US 41 N STE C | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 316026867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292626800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2019 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | BROOKS | ||||||||
| AuthorizedOfficialFirstName: | TROY | ||||||||
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| AuthorizedOfficialTitleorPosition: | SVP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 2923533397 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
No ID Information.