Healthcare Provider Details

I. General information

NPI: 1013459551
Provider Name (Legal Business Name): EFFINGHAM ORTHOPEDIC PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2016
Last Update Date: 07/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 TOWNE PARK DR W SUITE 303-304
RINCON GA
31326-5182
US

IV. Provider business mailing address

459 HIGHWAY 119 S ATTN.: ALIA ALLEN - MEDICAL STAFF OFFICE
SPRINGFIELD GA
31329-3021
US

V. Phone/Fax

Practice location:
  • Phone: 912-826-3111
  • Fax: 912-826-3120
Mailing address:
  • Phone: 912-754-0175
  • Fax: 912-754-6395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: FRANCINE BAKER-WITT
Title or Position: INTERIM CEO
Credential: RN,MBA,CHNA
Phone: 912-754-0142