Healthcare Provider Details

I. General information

NPI: 1083782189
Provider Name (Legal Business Name): MEMORIAL HEALTH URGENTONE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 05/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 MEDICAL PARK DR
POOLER GA
31322-1956
US

IV. Provider business mailing address

PO BOX 102482
ATLANTA GA
30368-2482
US

V. Phone/Fax

Practice location:
  • Phone: 912-748-1515
  • Fax: 912-748-7707
Mailing address:
  • Phone: 912-748-1515
  • Fax: 912-748-7707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ROBIN J. MADDOX
Title or Position: PROVIDER ENROLLMENT COORDINATOR
Credential:
Phone: 912-350-9335