MEDICARE: SOUTHERN OB GYN ASSOCIATES P C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801951454
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN OB GYN ASSOCIATES P C

Provider Business Mailing Address
First Line	:	220 NORTHSIDE DR
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31602-1858
Country	:	US
Telephone Number	:	229-241-2800
Fax Number	:	229-241-0454

Provider Business Practice Location Address
First Line	:	220 NORTHSIDE DR
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31602-1858
Country	:	US
Telephone Number	:	229-241-2800
Fax Number	:	229-241-0454

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	RANDY J JOHNSON
Credential	:
Telephone Number	:	229-241-2800

Provider Enumeration Date	:	12/26/2006
Last Update Date	:	06/18/2010

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