Healthcare Provider Details

I. General information

NPI: 1144326307
Provider Name (Legal Business Name): OLD MOULTRIE SURGICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 08/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 OLD MOULTRIE ROAD SUITE 3
ST AUGUSTINE FL
32086-4198
US

IV. Provider business mailing address

P O BOX 3127
ST AUGUSTINE FL
32085-3127
US

V. Phone/Fax

Practice location:
  • Phone: 904-797-6627
  • Fax: 904-797-6028
Mailing address:
  • Phone: 904-797-6627
  • Fax: 904-797-6028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number1089
License Number StateFL

VIII. Authorized Official

Name: GEORGE EDWARD SADOWSKI
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 904-797-6627