Basic Information
| Provider Information | |||||||||
| NPI: | 1518629427 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH GEORGIA HEART AND VASCULAR ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 206 HOSPITAL DR STE A | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310212560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782723525 | ||||||||
| FaxNumber: | 4782723589 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 HOSPITAL DR STE A | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310212560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782723525 | ||||||||
| FaxNumber: | 4782723589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2021 | ||||||||
| LastUpdateDate: | 10/07/2021 | ||||||||
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| AuthorizedOfficialLastName: | DANIEL | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4782723525 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246XC2903X | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Spec/Tech, Cardiovascular | Vascular Specialist | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.