Healthcare Provider Details

I. General information

NPI: 1760627699
Provider Name (Legal Business Name): STATTESBORO ORTHOPAEDIC CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2008
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1497 FAIR RD STE 101
STATESBORO GA
30458-0823
US

IV. Provider business mailing address

1497 FAIR RD STE 101
STATESBORO GA
30458-0823
US

V. Phone/Fax

Practice location:
  • Phone: 912-225-3760
  • Fax: 912-225-3767
Mailing address:
  • Phone: 912-225-3760
  • Fax: 912-225-3767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number034484
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number034484
License Number StateGA

VIII. Authorized Official

Name: WILLIAM STEPHEN TANKERSLEY
Title or Position: MD-OWNER
Credential: M.D.
Phone: 912-225-3760