Healthcare Provider Details

I. General information

NPI: 1508144981
Provider Name (Legal Business Name): PROVIDENT HEALTH SURGICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2011
Last Update Date: 08/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 WATERS AVE SUITE 403
SAVANNAH GA
31404-6220
US

IV. Provider business mailing address

4700 WATERS AVE SUITE 403
SAVANNAH GA
31404-6220
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 Code2086X0206X
TaxonomySurgical Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery 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