Healthcare Provider Details

I. General information

NPI: 1316501372
Provider Name (Legal Business Name): SOUTH GEORGIA PHYSICIANS GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2019
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 HABERSHAM DR
WAYCROSS GA
31501-5306
US

IV. Provider business mailing address

204 E 15TH STREET
ALMA GA
31510-2908
US

V. Phone/Fax

Practice location:
  • Phone: 912-287-1130
  • Fax: 912-287-9114
Mailing address:
  • Phone: 912-632-2952
  • Fax: 912-632-8682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: CHERYL CRAWFORD DUBOSE
Title or Position: CFO
Credential:
Phone: 912-632-8961