Healthcare Provider Details

I. General information

NPI: 1861568040
Provider Name (Legal Business Name): SURGICAL SPECIALISTS OF GEORGIA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 07/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 JESSE JEWELL PKWY SE SUITE 300
GAINESVILLE GA
30501-3871
US

IV. Provider business mailing address

1250 JESSE JEWELL PKWY SE SUITE 300
GAINESVILLE GA
30501-3871
US

V. Phone/Fax

Practice location:
  • Phone: 770-534-0110
  • Fax: 770-534-2555
Mailing address:
  • Phone: 770-534-0110
  • Fax: 770-534-2555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN171688NP
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number050992
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number059108
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number035736
License Number StateGA

VIII. Authorized Official

Name: MS. AMY D SEABOLT
Title or Position: BUSINESS OFFICE MANAGER
Credential: BSBA
Phone: 770-534-0110