1144454059 NPI number — SOUTH GEORGIA VASCULAR CLINIC

Table of content: (NPI 1144454059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144454059 NPI number — SOUTH GEORGIA VASCULAR CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH GEORGIA VASCULAR CLINIC
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:
Provider Other Organization Name Type Code:
6
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:
1144454059
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 18TH ST E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIFTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31794-3648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-382-9733
Provider Business Mailing Address Fax Number:
229-387-6161

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 18TH ST E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIFTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31794-3648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-382-9733
Provider Business Practice Location Address Fax Number:
229-387-6161
Provider Enumeration Date:
05/06/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CRUM
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
Authorized Official Title or Position:
VP/CFO
Authorized Official Telephone Number:
229-353-6146

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X , with the licence number:  031466 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1003883612 . This is a "NPI/WILLIAM KAISER, MD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1154356889 . This is a "NPI/BRAD HOLT PA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 205810921C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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