1134367550 NPI number — VIDALIA ORTHOPEDIC CENTER, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134367550 NPI number — VIDALIA ORTHOPEDIC CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIDALIA ORTHOPEDIC CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHEAST REGIONAL PRIMARY CARE CORP
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134367550
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 407
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIDALIA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30475-0407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-538-0040
Provider Business Mailing Address Fax Number:
912-538-8133

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1707 MEADOWS LN
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
VIDALIA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30474-7200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-538-0040
Provider Business Practice Location Address Fax Number:
912-538-8133
Provider Enumeration Date:
01/22/2009

Additional Information

Authorized Official

Authorized Official Last Name:
OSTEEN
Authorized Official First Name:
TONY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
912-538-5314

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 333690169C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 489633273A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 333690169B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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