1831426360 NPI number — SOUTHEAST GEORGIA NEUROLOGICAL CENTERS, PC

Table of content: (NPI 1427785682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831426360 NPI number — SOUTHEAST GEORGIA NEUROLOGICAL CENTERS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST GEORGIA NEUROLOGICAL CENTERS, PC
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:
1831426360
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 15694
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31416-2394
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-354-7553
Provider Business Mailing Address Fax Number:
912-354-7559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 OGLETHORPE PROFESSIONAL BLVD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31406-4883
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-354-7553
Provider Business Practice Location Address Fax Number:
912-354-7559
Provider Enumeration Date:
11/04/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
KIMBLE
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
912-308-0444

Provider Taxonomy Codes

  • Taxonomy code: 2084N0402X , with the licence number:  063231 , 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)





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