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General NPI Number Information
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NPI Number | 1609062215
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Entity Type | Organization
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Legal Business Name | SOUTH GEORGIA VASCULAR INSTITUTE
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Dates
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Enumeration Date | 09/18/2007
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Last Update Date | 09/18/2007
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Provider Practice Location Address
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Address Line | 903 S BROAD ST
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City | THOMASVILLE
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State | GA
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Zip | 31792-6114
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Country | US
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Telephone | 229-551-0024
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Fax | 229-551-0254
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Provider Business Mailing Address
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Address Line | 903 S BROAD ST
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City | THOMASVILLE
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State | GA
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Zip | 31792-6114
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Country | US
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Telephone | 229-551-0024
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Fax | 229-551-0254
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. ROBERT LEWUS CIRILLO JR.
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Credential | M.D.
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Telephone | 229-551-0024
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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 | 056092
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License Number State | GA
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