Healthcare Provider Details

I. General information

NPI: 1558412023
Provider Name (Legal Business Name): STATESBORO HMA PHYSICIAN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2007
Last Update Date: 12/13/2022
Certification Date: 12/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1499 FAIR RD
STATESBORO GA
30458-1683
US

IV. Provider business mailing address

4000 MERIDIAN BLVD
FRANKLIN TN
37067-6325
US

V. Phone/Fax

Practice location:
  • Phone: 912-871-5437
  • Fax: 912-871-8595
Mailing address:
  • Phone: 615-465-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER L JACKSON
Title or Position: SR DUR PROV ENROLLMENT
Credential:
Phone: 615-465-7000