Provider Demographics
NPI:1104272780
Name:ENT OF SOUTH GEORGIA SURGERY CENTER LLC
Entity type:Organization
Organization Name:ENT OF SOUTH GEORGIA SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:V
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-244-2562
Mailing Address - Street 1:2805 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-5922
Mailing Address - Country:US
Mailing Address - Phone:229-244-2562
Mailing Address - Fax:229-249-0000
Practice Address - Street 1:2805 N OAK ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-5922
Practice Address - Country:US
Practice Address - Phone:229-244-2562
Practice Address - Fax:229-249-0000
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAR, NOSE, THROAT AND ALLERGY ASSOCIATES OF SOUTH GEORGIA PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-12
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000655146AMedicaid
GA000834589AMedicaid
GA000946668AMedicaid
GAH56636Medicare UPIN
GA000946668AMedicaid
GAG98411Medicare UPIN