Healthcare Provider Details

I. General information

NPI: 1336560952
Provider Name (Legal Business Name): SOUTH GEORGIA PHYSICIANS GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2013
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 E 15TH ST
ALMA GA
31510
US

IV. Provider business mailing address

204 E 15TH ST
ALMA GA
31510-2908
US

V. Phone/Fax

Practice location:
  • Phone: 912-632-0314
  • Fax: 912-632-2554
Mailing address:
  • Phone: 912-632-0314
  • Fax: 912-632-2554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHERYL CRAWFORD DUBOSE
Title or Position: CFO
Credential:
Phone: 912-632-8961