Provider Demographics
NPI:1194068478
Name:SOUTH EAST SPONE CARE & PAIN MGMT
Entity type:Organization
Organization Name:SOUTH EAST SPONE CARE & PAIN MGMT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ORTELIO
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-233-6811
Mailing Address - Street 1:7450 SKIDAWAY RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406
Mailing Address - Country:US
Mailing Address - Phone:912-233-6811
Mailing Address - Fax:912-544-0864
Practice Address - Street 1:7450 SKIDAWAY RD
Practice Address - Street 2:SUITE B
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406
Practice Address - Country:US
Practice Address - Phone:912-233-6811
Practice Address - Fax:912-544-0864
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTEAST SPINE CARE AND PAIN MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000966139DMedicaid
GA09BBBBMMedicare PIN
GA000966139DMedicaid