Healthcare Provider Details

I. General information

NPI: 1033324629
Provider Name (Legal Business Name): OGEECHEE OBGYN, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 BRAMPTON AVE
STATESBORO GA
30458-0851
US

IV. Provider business mailing address

1310 BRAMPTON AVE
STATESBORO GA
30458-0851
US

V. Phone/Fax

Practice location:
  • Phone: 912-871-6206
  • Fax: 912-681-8558
Mailing address:
  • Phone: 912-871-6206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: TONYA K CLARK
Title or Position: OFFICE MANAGER
Credential:
Phone: 912-871-6206