Healthcare Provider Details

I. General information

NPI: 1073709432
Provider Name (Legal Business Name): ST. MARYS OBSTETRICS & GYNECOLOGY, P. C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 LAKESHORE PT
SAINT MARYS GA
31558-3843
US

IV. Provider business mailing address

203 LAKESHORE PT
SAINT MARYS GA
31558-3843
US

V. Phone/Fax

Practice location:
  • Phone: 912-729-6600
  • Fax: 912-729-6616
Mailing address:
  • Phone: 912-729-6600
  • Fax: 912-729-6616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberGA022993
License Number StateGA

VIII. Authorized Official

Name: DR. FAREED Z KADUM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 912-729-6600