Healthcare Provider Details

I. General information

NPI: 1346534831
Provider Name (Legal Business Name): SOUTHEASTERN OB/GYN CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2011
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5311 PAULSEN ST
SAVANNAH GA
31405-4800
US

IV. Provider business mailing address

5311 PAULSEN ST
SAVANNAH GA
31405-4800
US

V. Phone/Fax

Practice location:
  • Phone: 912-355-1111
  • Fax: 912-352-7136
Mailing address:
  • Phone: 912-355-1111
  • Fax: 912-352-7136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number038019
License Number StateGA

VIII. Authorized Official

Name: DR. MICHAEL J JACKSON
Title or Position: OWNER
Credential: M.D.
Phone: 912-355-1111