Healthcare Provider Details

I. General information

NPI: 1720228216
Provider Name (Legal Business Name): SURGEONCARE PHYSICIANS OF GEORGIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2009
Last Update Date: 08/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 HOSPITAL RD SUITE 1
COMMERCE GA
30529-1143
US

IV. Provider business mailing address

PO BOX 5048
MACON GA
31208-5048
US

V. Phone/Fax

Practice location:
  • Phone: 706-336-8485
  • Fax: 336-553-3325
Mailing address:
  • Phone: 706-336-8485
  • Fax: 336-553-3325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. ANTHONY C ROBERTSON
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 336-553-3322