Basic Information
Provider Information | |||||||||
NPI: | 1720625296 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHWELL AMBULATORY INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SOUTHWELL VALDOSTA ENDOSCOPY CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 907 E 18TH STREET | ||||||||
Address2: | SUITE 400 | ||||||||
City: | TIFTON | ||||||||
State: | GA | ||||||||
PostalCode: | 317943684 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2293533422 | ||||||||
FaxNumber: | 2293536060 | ||||||||
Practice Location | |||||||||
Address1: | 410 CONNELL RD STE B | ||||||||
Address2: |   | ||||||||
City: | VALDOSTA | ||||||||
State: | GA | ||||||||
PostalCode: | 316021898 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2292441570 | ||||||||
FaxNumber: | 2292994291 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/04/2019 | ||||||||
LastUpdateDate: | 10/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BROOKS | ||||||||
AuthorizedOfficialFirstName: | TROY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SVP/CFP | ||||||||
AuthorizedOfficialTelephone: | 2293533397 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
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.