Healthcare Provider Details

I. General information

NPI: 1770078032
Provider Name (Legal Business Name): SOUTHLAND STEPHENS HOSPITALIST GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2018
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 HOSPITAL DR
TOCCOA GA
30577-6820
US

IV. Provider business mailing address

PO BOX 1276
THOMASVILLE GA
31799-1276
US

V. Phone/Fax

Practice location:
  • Phone: 706-282-4200
  • Fax:
Mailing address:
  • Phone: 229-236-0831
  • Fax: 229-236-0871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number StateGA

VIII. Authorized Official

Name: MRS. STEPHANIE FLETCHER
Title or Position: CFO
Credential:
Phone: 229-520-7115