Healthcare Provider Details

I. General information

NPI: 1083753404
Provider Name (Legal Business Name): THE WIREGRASS MEDICAL & SURGICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 N WILEY AVE
DONALSONVILLE GA
39845-1120
US

IV. Provider business mailing address

804 N WILEY AVE
DONALSONVILLE GA
39845-1120
US

V. Phone/Fax

Practice location:
  • Phone: 229-524-2706
  • Fax: 229-524-1272
Mailing address:
  • Phone: 229-524-2706
  • Fax: 229-524-1272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number033591
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number9288
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number019644
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number051586
License Number StateGA

VIII. Authorized Official

Name: APRIL CLANTON MASSEY
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 229-524-2706