Healthcare Provider Details

I. General information

NPI: 1154322899
Provider Name (Legal Business Name): JANISE HARTZOG WHITESELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 08/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 DAN PROCTOR DR SUITE 2100
SAINT MARYS GA
31558-3894
US

IV. Provider business mailing address

2060 DAN PROCTOR DR SUITE 2100
SAINT MARYS GA
31558-3894
US

V. Phone/Fax

Practice location:
  • Phone: 912-882-6767
  • Fax: 912-882-6411
Mailing address:
  • Phone: 912-882-6767
  • Fax: 912-882-6411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number047867
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: