Healthcare Provider Details

I. General information

NPI: 1588082358
Provider Name (Legal Business Name): HOSPITALMD OF EAST GEORGIA IP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2014
Last Update Date: 03/31/2014
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

PO BOX 896140
CHARLOTTE NC
28289-6140
US

V. Phone/Fax

Practice location:
  • Phone: 912-739-2611
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: RYAN ZONDERVAN
Title or Position: VICE PRESIDENT
Credential:
Phone: 888-898-3294