1164069472 NPI number — SOUTHWELL AMBULATORY INC

Table of content: (NPI 1164069472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164069472 NPI number — SOUTHWELL AMBULATORY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWELL AMBULATORY INC
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:
SOUTHWELL GASTROENTEROLOGY
Provider Other Organization Name Type Code:
3
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:
1164069472
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
907 E 18TH STREET
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
TIFTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31794-3684
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-353-3422
Provider Business Mailing Address Fax Number:
229-353-6060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 CONNELL ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALDOSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31602-1407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-244-1570
Provider Business Practice Location Address Fax Number:
229-299-4291
Provider Enumeration Date:
12/05/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BROOKS
Authorized Official First Name:
TROY
Authorized Official Middle Name:
Authorized Official Title or Position:
SVP/CFO
Authorized Official Telephone Number:
229-353-3397

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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