Basic Information
| Provider Information | |||||||||
| NPI: | 1851958607 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHLAND DODGE EMERGENCY MEDICAL SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1276 | ||||||||
| Address2: | |||||||||
| City: | THOMASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317991276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292360831 | ||||||||
| FaxNumber: | 2292360871 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 GRIFFIN AVE | ||||||||
| Address2: | |||||||||
| City: | EASTMAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310236720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784484000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2019 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | FLETCHER | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2292360831 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.