Healthcare Provider Details

I. General information

NPI: 1770224495
Provider Name (Legal Business Name): ENSIGN FAMILY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 PLANT AVE
WAYCROSS GA
31501-3537
US

IV. Provider business mailing address

1302 PLANT AVE
WAYCROSS GA
31501-3537
US

V. Phone/Fax

Practice location:
  • Phone: 912-490-5080
  • Fax: 912-490-5081
Mailing address:
  • Phone: 912-490-5080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SHAD STORMANT
Title or Position: PRESIDENT
Credential: MD
Phone: 912-490-5080