Provider Demographics
NPI:1316346471
Name:STATESBORO ENT SURGICAL CENTER
Entity type:Organization
Organization Name:STATESBORO ENT SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:CREWS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-764-8200
Mailing Address - Street 1:106 PROCTOR ST
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-1351
Mailing Address - Country:US
Mailing Address - Phone:912-764-8200
Mailing Address - Fax:
Practice Address - Street 1:106 PROCTOR ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-1351
Practice Address - Country:US
Practice Address - Phone:912-764-8200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN123377367500000X
GARN139429367500000X
GARN179667367500000X
GARN177700367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1750612057OtherNPI
GA1629026851OtherNPI
GA1033285838OtherNPI
GA1437151123OtherNPI