Healthcare Provider Details

I. General information

NPI: 1043548217
Provider Name (Legal Business Name): PATRICK JUSTIN LANCASTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2009
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16915 HIGHWAY 67
STATESBORO GA
30458-5819
US

IV. Provider business mailing address

PO BOX 15359
SAVANNAH GA
31416-2059
US

V. Phone/Fax

Practice location:
  • Phone: 912-681-2500
  • Fax: 912-681-2025
Mailing address:
  • Phone: 912-644-5300
  • Fax: 912-644-5282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number75301
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD.35898
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number075301
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: