Healthcare Provider Details

I. General information

NPI: 1538421177
Provider Name (Legal Business Name): WAYNE SJC MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2012
Last Update Date: 08/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 PEACHTREE ST
JESUP GA
31545-0244
US

IV. Provider business mailing address

320 PEACHTREE ST
JESUP GA
31545-0244
US

V. Phone/Fax

Practice location:
  • Phone: 912-427-7790
  • Fax: 912-427-7707
Mailing address:
  • Phone: 912-427-7790
  • Fax: 912-427-7707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH P IERARDI
Title or Position: CEO
Credential:
Phone: 912-427-7790