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General NPI Number Information
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NPI Number | 1013535657
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Entity Type | Organization
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Legal Business Name | STATESBORO MEDICAL GROUP, LLC
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Dates
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Enumeration Date | 07/09/2020
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Last Update Date | 09/11/2020
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Provider Practice Location Address
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Address Line | 1176 BRAMPTON AVE
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City | STATESBORO
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State | GA
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Zip | 30458-0847
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Country | US
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Telephone | 912-259-9474
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Fax |
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Provider Business Mailing Address
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Address Line | 106 IRONGATE PL
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City | STATESBORO
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State | GA
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Zip | 30458-9173
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Country | US
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Telephone | 912-531-7338
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. SREEVALLI DEGA
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Credential | MD
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Telephone | 912-259-9474
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number |
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License Number State |
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