Basic Information
| Provider Information | |||||||||
| NPI: | 1245273812 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SO | ||||||||
| FirstName: | LAURENCE | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SO | ||||||||
| OtherFirstName: | LAURENCE | ||||||||
| OtherMiddleName: | S. | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 500 W 3RD AVE | ||||||||
| Address2: | STE 101 | ||||||||
| City: | ALBANY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317011985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293125800 | ||||||||
| FaxNumber: | 2293125853 | ||||||||
| Practice Location | |||||||||
| Address1: | 417 W 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317011943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293121000 | ||||||||
| FaxNumber: | 2293125853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 03/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 200100468 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 072131 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1245273812 | 05 | NC | MEDICAID | NC1992 | 05 | SC | MEDICAID | 8912824 | 05 | NC | MEDICAID |