Healthcare Provider Details

I. General information

NPI: 1992468482
Provider Name (Legal Business Name): PREMIER UROGYNECOLOGY OF TALLAHASSEE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1963 VILLAGE GREEN WAY
TALLAHASSEE FL
32308-3833
US

IV. Provider business mailing address

PO BOX 2876
MOULTRIE GA
31776-2876
US

V. Phone/Fax

Practice location:
  • Phone: 229-502-9788
  • Fax:
Mailing address:
  • Phone: 229-891-9131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number
License Number State

VIII. Authorized Official

Name: SANDRA JORDAN
Title or Position: PROVIDER ENROLLMENT COORDINATOR
Credential:
Phone: 229-891-9131