Healthcare Provider Details

I. General information

NPI: 1497547178
Provider Name (Legal Business Name): SOUTHEASTERN RHEUMATOLOGY ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2025
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 RUSHING LN STE B
STATESBORO GA
30458-6027
US

IV. Provider business mailing address

700 S ENOTA DR NE
GAINESVILLE GA
30501-2403
US

V. Phone/Fax

Practice location:
  • Phone: 912-210-0276
  • Fax: 912-428-7201
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL CULLEN
Title or Position: CIO
Credential:
Phone: 770-714-7857