Basic Information
| Provider Information | |||||||||
| NPI: | 1558438226 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEORGE | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2817 REILLY ROAD | ||||||||
| Address2: | |||||||||
| City: | FT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109078176 | ||||||||
| FaxNumber: | 9109077463 | ||||||||
| Practice Location | |||||||||
| Address1: | 2817 REILLY ROAD | ||||||||
| Address2: | |||||||||
| City: | FT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109078176 | ||||||||
| FaxNumber: | 9109077463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 01/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 16766 | AL | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 9601613 | NC | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 115804 | 05 | AL | MEDICAID | 06302268 | 05 | MS | MEDICAID | 73020227 | 01 | AL | BCBS OF AL | OTHER |