MEDICARE: SOUTH GEORGIA VEIN CENTERS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0129X	Vascular Surgery Physician

General Provider Information

NPI Number	:	1669405452
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH GEORGIA VEIN CENTERS LLC

Provider Business Mailing Address
First Line	:	3338 L1 COUNTRY CLUB RD PMB 342
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31605
Country	:	US
Telephone Number	:	229-259-9666
Fax Number	:	229-253-0064

Provider Business Practice Location Address
First Line	:	3338 COUNTRY CLUB RD # M
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31605-1044
Country	:	US
Telephone Number	:	229-259-9666
Fax Number	:	229-253-0064

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GREGORY D MARTIN
Credential	:	M.D.
Telephone Number	:	229-259-9666

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	10/07/2024

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