Healthcare Provider Details

I. General information

NPI: 1285810366
Provider Name (Legal Business Name): SOUTH GEORGIA ALLERGY CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2008
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 PARKWOOD DR SUITE B
BRUNSWICK GA
31520-4758
US

IV. Provider business mailing address

PO BOX 1813
BRUNSWICK GA
31521-1813
US

V. Phone/Fax

Practice location:
  • Phone: 912-262-9288
  • Fax: 912-262-9994
Mailing address:
  • Phone: 912-262-9288
  • Fax: 912-262-9994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberGA023506
License Number StateGA

VIII. Authorized Official

Name: KELLY M DIRTING
Title or Position: BILLING MGR
Credential: CPC
Phone: 912-262-9289