1942374343 NPI number — SOUTH GEORGIA CSB

Table of content: (NPI 1942374343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942374343 NPI number — SOUTH GEORGIA CSB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH GEORGIA CSB
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:
1942374343
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
340 TIFTON ELDORADO ROAD
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
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-391-2350
Provider Business Mailing Address Fax Number:
229-386-7099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
340 TIFTON ELDORADO ROAD
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-391-2350
Provider Business Practice Location Address Fax Number:
229-386-7099
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
POWELL
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
229-671-6101

Provider Taxonomy Codes

  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 777050079A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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