Healthcare Provider Details

I. General information

NPI: 1467960146
Provider Name (Legal Business Name): SOUTHLAND EVANS HOSPITALIST GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N RIVER ST
CLAXTON GA
30417-1659
US

IV. Provider business mailing address

100 S MADISON ST
THOMASVILLE GA
31792-5473
US

V. Phone/Fax

Practice location:
  • Phone: 912-739-5000
  • Fax:
Mailing address:
  • Phone: 229-236-0831
  • Fax: 229-236-0871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number StateGA

VIII. Authorized Official

Name: STEPHANIE FLETCHER
Title or Position: CFO
Credential:
Phone: 229-236-0831