Healthcare Provider Details

I. General information

NPI: 1811233828
Provider Name (Legal Business Name): SJC MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2012
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 EISENHOWER DR
SAVANNAH GA
31406-2668
US

IV. Provider business mailing address

602 E 72ND ST
SAVANNAH GA
31405-4913
US

V. Phone/Fax

Practice location:
  • Phone: 912-819-9100
  • Fax: 912-819-9100
Mailing address:
  • Phone: 912-819-7878
  • Fax: 912-819-7850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: DONNA J STEPHENS
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 912-819-7878