Healthcare Provider Details

I. General information

NPI: 1265480172
Provider Name (Legal Business Name): ANGELA SELLERS GERGUIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 BRAMPTON AVE SUITE A
STATESBORO GA
30458-0850
US

IV. Provider business mailing address

1203 BRAMPTON AVE
STATESBORO GA
30458-0850
US

V. Phone/Fax

Practice location:
  • Phone: 912-871-7890
  • Fax: 912-871-7898
Mailing address:
  • Phone: 912-871-7890
  • Fax: 912-871-7898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number047261
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number47261
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number47261
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: