Basic Information
| Provider Information | |||||||||
| NPI: | 1336337344 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SURGICAL ASSOCIATES OF SOUTH GEORGIA, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3004 2ND ST SE | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317686797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299851080 | ||||||||
| FaxNumber: | 2298909743 | ||||||||
| Practice Location | |||||||||
| Address1: | 3004 2ND ST SE | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317686797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299851080 | ||||||||
| FaxNumber: | 2298909743 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2007 | ||||||||
| LastUpdateDate: | 10/04/2007 | ||||||||
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| AuthorizedOfficialLastName: | CROFT | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2299851080 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | GRP2637 | 01 | GA | MEDICARE GROUP NUMBER | OTHER |