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General NPI Number Information
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NPI Number | 1144454059
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Entity Type | Organization
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Legal Business Name | SOUTH GEORGIA VASCULAR CLINIC
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Dates
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Enumeration Date | 05/06/2009
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Last Update Date | 05/06/2009
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Provider Practice Location Address
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Address Line | 901 18TH ST E
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City | TIFTON
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State | GA
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Zip | 31794-3648
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Country | US
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Telephone | 229-382-9733
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Fax | 229-387-6161
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Provider Business Mailing Address
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Address Line | 901 18TH ST E
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City | TIFTON
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State | GA
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Zip | 31794-3648
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Country | US
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Telephone | 229-382-9733
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Fax | 229-387-6161
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Authorized Official
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Title or Position | VP/CFO
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Name | MR. DENNIS CRUM
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Credential |
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Telephone | 229-353-6146
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number | 031466
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License Number State | GA
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