Provider Demographics
NPI:1194985093
Name:VIDALIA PULMONOLOGY CENTER, LLC
Entity type:Organization
Organization Name:VIDALIA PULMONOLOGY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:M
Authorized Official - Last Name:O'STEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-538-5314
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0407
Mailing Address - Country:US
Mailing Address - Phone:912-538-8105
Mailing Address - Fax:912-538-8109
Practice Address - Street 1:1811 EDWINA DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8963
Practice Address - Country:US
Practice Address - Phone:912-538-8105
Practice Address - Fax:912-538-8109
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST REGIONAL PRIMARY CARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-13
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty