Healthcare Provider Details

I. General information

NPI: 1811966369
Provider Name (Legal Business Name): OGEECHEE OB-GYN, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1497 FAIR RD SUITE 300
STATESBORO GA
30458-0822
US

IV. Provider business mailing address

1497 FAIR RD SUITE 300
STATESBORO GA
30458-0822
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number010585
License Number StateGA

VIII. Authorized Official

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