Basic Information
| Provider Information | |||||||||
| NPI: | 1770587560 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAMBSGANS | ||||||||
| FirstName: | SAL | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 933049 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 311933049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663135266 | ||||||||
| FaxNumber: | 2053135298 | ||||||||
| Practice Location | |||||||||
| Address1: | 2260 WRIGHTSBORO RD | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309044764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663135266 | ||||||||
| FaxNumber: | 2053135298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 09/26/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 044139 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | G44139 | 05 | SC | MEDICAID | 000754993F | 05 | GA | MEDICAID |