Healthcare Provider Details

I. General information

NPI: 1912019308
Provider Name (Legal Business Name): ORTHOPAEDIC SPECIALISTS OF SOUTH GEORGIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W ONEIDA ST
WAYCROSS GA
31501-5337
US

IV. Provider business mailing address

PO BOX 2267
WAYCROSS GA
31502-2267
US

V. Phone/Fax

Practice location:
  • Phone: 912-287-1130
  • Fax: 912-287-1231
Mailing address:
  • Phone: 912-287-1130
  • Fax: 912-287-1231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number4309190001
License Number StateGA

VIII. Authorized Official

Name: ALESHA HERRING
Title or Position: PRACTICE MANAGER
Credential:
Phone: 912-287-1130