=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841348521
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STATESBORO OB-GYN SPECIALISTS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2007
-----------------------------------------------------
Last Update Date | 09/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1523 FAIR RD
-----------------------------------------------------
City | STATESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30458-6025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-871-2000
-----------------------------------------------------
Fax | 912-871-2500
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1958
-----------------------------------------------------
City | STATESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30459-1958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-871-2000
-----------------------------------------------------
Fax | 912-871-2500
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MARY COLLINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 912-871-2000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------