Healthcare Provider Details

I. General information

NPI: 1518629427
Provider Name (Legal Business Name): SOUTH GEORGIA HEART AND VASCULAR ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 HOSPITAL DR STE A
DUBLIN GA
31021-2560
US

IV. Provider business mailing address

206 HOSPITAL DR STE A
DUBLIN GA
31021-2560
US

V. Phone/Fax

Practice location:
  • Phone: 478-272-3525
  • Fax: 478-272-3589
Mailing address:
  • Phone: 478-272-3525
  • Fax: 478-272-3589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246XC2903X
TaxonomyVascular Specialist/Technologist Cardiovascular
License Number
License Number State

VIII. Authorized Official

Name: GARY DANIEL
Title or Position: OWNER
Credential: MD
Phone: 478-272-3525