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General NPI Number Information
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NPI Number | 1285662866
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Entity Type | Organization
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Legal Business Name | STATESBORO UROLOGIC CLINIC, PC
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Dates
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Enumeration Date | 06/30/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 412 NORTHSIDE DR E SUITE 500
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City | STATESBORO
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State | GA
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Zip | 30458-4802
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Country | US
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Telephone | 912-764-6808
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Fax | 912-764-2436
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Provider Business Mailing Address
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Address Line | 412 NORTHSIDE DR E SUITE 500
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City | STATESBORO
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State | GA
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Zip | 30458-4802
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Country | US
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Telephone | 912-764-6808
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Fax | 912-764-2436
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Authorized Official
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Title or Position | PRESIDENT
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Name | PAUL J TILSON
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Credential | MD
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Telephone | 912-764-6808
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 046818
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 020839
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License Number State | GA
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