Healthcare Provider Details

I. General information

NPI: 1497330625
Provider Name (Legal Business Name): SOUTHWELL AMBULATORY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2021
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2922 N OAK ST STE C
VALDOSTA GA
31602-1885
US

IV. Provider business mailing address

410 CONNELL RD
VALDOSTA GA
31602-1898
US

V. Phone/Fax

Practice location:
  • Phone: 229-262-6819
  • Fax:
Mailing address:
  • Phone: 229-353-6889
  • Fax: 229-219-1631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TROY BROOKS
Title or Position: SVP/CFO
Credential:
Phone: 229-353-3397