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General NPI Number Information
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NPI Number | 1437299740
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Entity Type | Organization
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Legal Business Name | SOUTH GA SPINE CARE INSTITUTE
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Dates
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Enumeration Date | 02/07/2007
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Last Update Date | 12/16/2015
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Provider Practice Location Address
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Address Line | 8 LIVE OAK CT
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City | MOULTRIE
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State | GA
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Zip | 31768-6783
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Country | US
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Telephone | 229-890-6612
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Fax | 229-890-6621
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Provider Business Mailing Address
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Address Line | 8 LIVE OAK CT
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City | MOULTRIE
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State | GA
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Zip | 31768-6783
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Country | US
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Telephone | 229-890-6612
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Fax | 229-890-6621
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Authorized Official
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Title or Position | DOCTOR
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Name | ANDREW GREGORY CORDISTA
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Credential | MD
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Telephone | 229-890-6612
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XS0117X
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Taxonomy Name | Orthopaedic Surgery of the Spine Physician
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License Number | 051451
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License Number State | GA
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