Healthcare Provider Details

I. General information

NPI: 1104113307
Provider Name (Legal Business Name): PROVIDENT HEALTH SURGICAL ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2011
Last Update Date: 07/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 WATERS AVE SUITE 405
SAVANNAH GA
31404-6220
US

IV. Provider business mailing address

4700 WATERS AVE SUITE 405
SAVANNAH GA
31404-6220
US

V. Phone/Fax

Practice location:
  • Phone: 912-350-2700
  • Fax: 912-350-2715
Mailing address:
  • Phone: 912-350-2700
  • Fax: 912-350-2715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. ROBIN J. MADDOX
Title or Position: PROVIDER ENROLLMENT COORDINATOR
Credential:
Phone: 912-350-9335