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General NPI Number Information
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NPI Number | 1396791976
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Entity Type | Organization
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Legal Business Name | STATESBORO ENT & FPS CLINIC, P.C.
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Dates
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Enumeration Date | 05/26/2006
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Last Update Date | 01/05/2011
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Provider Practice Location Address
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Address Line | 106 PROCTOR ST
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City | STATESBORO
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State | GA
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Zip | 30458-1351
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Country | US
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Telephone | 912-764-8200
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Fax | 912-489-2954
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Provider Business Mailing Address
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Address Line | 106 PROCTOR ST
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City | STATESBORO
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State | GA
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Zip | 30458-1351
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Country | US
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Telephone | 912-764-8200
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Fax | 912-489-2954
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Authorized Official
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Title or Position | OWNER
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Name | THOMAS M CREWS
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Credential | MD
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Telephone | 912-764-8200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 024663
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License Number State | GA
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