Provider Demographics
NPI:1194785170
Name:EMERGENCY MEDICINE SOUTH LLC
Entity type:Organization
Organization Name:EMERGENCY MEDICINE SOUTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEBOSITS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-259-4660
Mailing Address - Street 1:PO BOX 402059
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2059
Mailing Address - Country:US
Mailing Address - Phone:229-333-1000
Mailing Address - Fax:
Practice Address - Street 1:2501 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602
Practice Address - Country:US
Practice Address - Phone:229-333-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258338100Medicaid
GA300033708AMedicaid
158191000OtherFECA US DEPT OF LABOR
GA5272824401OtherBLUE CROSS BLUE SHIELD
FL256338100Medicaid
GA300033708AMedicaid
GAGRP3293Medicare PIN
GA5272824401OtherBLUE CROSS BLUE SHIELD
GA300033708AMedicaid