Healthcare Provider Details

I. General information

NPI: 1912149907
Provider Name (Legal Business Name): PROVIDENT HEALTH SURGICAL ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4750 WATERS AVE SUITE 103
SAVANNAH GA
31404-6200
US

IV. Provider business mailing address

PO BOX 102019
ATLANTA GA
30368-2019
US

V. Phone/Fax

Practice location:
  • Phone: 912-350-2299
  • Fax: 912-350-2298
Mailing address:
  • Phone: 912-350-2299
  • Fax: 912-350-2298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number
License Number State

VIII. Authorized Official

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