Healthcare Provider Details

I. General information

NPI: 1750395182
Provider Name (Legal Business Name): RONALD LEE HURST M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4625 RAIN WOOD CIR
VALDOSTA GA
31602-0835
US

IV. Provider business mailing address

4625 RAIN WOOD CIR
VALDOSTA GA
31602-0835
US

V. Phone/Fax

Practice location:
  • Phone: 229-241-1913
  • Fax:
Mailing address:
  • Phone: 229-241-1913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number044940
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: