Provider Demographics
NPI:1194709667
Name:SOUTHERN DIABETES MANAGEMENT
Entity type:Organization
Organization Name:SOUTHERN DIABETES MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT - OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELANA
Authorized Official - Middle Name:S
Authorized Official - Last Name:CRANE
Authorized Official - Suffix:
Authorized Official - Credentials:MSM
Authorized Official - Phone:706-653-6524
Mailing Address - Street 1:1331 10TH AVE,
Mailing Address - Street 2:BLDG. 133
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904
Mailing Address - Country:US
Mailing Address - Phone:706-653-6524
Mailing Address - Fax:706-317-5432
Practice Address - Street 1:9000 MOORE RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-1292
Practice Address - Country:US
Practice Address - Phone:706-653-6524
Practice Address - Fax:706-317-5432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4785990002Medicare NSC