Healthcare Provider Details

I. General information

NPI: 1285963447
Provider Name (Legal Business Name): SAMANA ZULU MD FACS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2009
Last Update Date: 12/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 WRIGHTSBORO RD
AUGUSTA GA
30904-6233
US

IV. Provider business mailing address

2320 WRIGHTSBORO RD
AUGUSTA GA
30904-6233
US

V. Phone/Fax

Practice location:
  • Phone: 706-737-7922
  • Fax: 706-737-7968
Mailing address:
  • Phone: 706-737-7922
  • Fax: 706-737-7968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number059943
License Number StateGA

VIII. Authorized Official

Name: MR. JARMAUR R STALLINGS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 706-737-7922