=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952412413
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH GEORGIA SURGERY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 04/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 306 ISABELLA STREET
-----------------------------------------------------
City | WAYCROSS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31501-3636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-490-7246
-----------------------------------------------------
Fax | 912-490-7247
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 306 ISABELLA STREET
-----------------------------------------------------
City | WAYCROSS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31501-3636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-267-9000
-----------------------------------------------------
Fax | 912-267-9028
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHAEL J LUPI
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 912-267-9000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 111252ASCA
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------