Healthcare Provider Details

I. General information

NPI: 1639381171
Provider Name (Legal Business Name): GEORGIA PHYSICIAN SOUTH,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 03/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 CARTER AVE
BLACKSHEAR GA
31516
US

IV. Provider business mailing address

120 CARTER AVE
BLACKSHEAR GA
31516
US

V. Phone/Fax

Practice location:
  • Phone: 912-449-4426
  • Fax: 912-449-1517
Mailing address:
  • Phone: 912-449-4426
  • Fax: 912-449-1517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: SUSAN E BRICKLE
Title or Position: LAB SUPERVISOR
Credential: MD
Phone: 912-449-4426