Healthcare Provider Details

I. General information

NPI: 1407910607
Provider Name (Legal Business Name): SOUTH GEORGIA NEUROLOGICAL ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 18TH ST E STE 190
TIFTON GA
31794-3600
US

IV. Provider business mailing address

907 18TH ST E STE 190
TIFTON GA
31794-3600
US

V. Phone/Fax

Practice location:
  • Phone: 229-391-3390
  • Fax: 229-391-3399
Mailing address:
  • Phone: 229-391-3390
  • Fax: 229-391-3399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberGA042576
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberGA042576
License Number StateGA

VIII. Authorized Official

Name: DR. ANTHONY GEORGE GIATRAS
Title or Position: OWNER
Credential: M.D.
Phone: 229-391-3390