Provider Demographics
NPI:1316501372
Name:SOUTH GEORGIA PHYSICIANS GROUP, LLC
Entity type:Organization
Organization Name:SOUTH GEORGIA PHYSICIANS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:CRAWFORD
Authorized Official - Last Name:DUBOSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-632-8961
Mailing Address - Street 1:204 E 15TH STREET
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:GA
Mailing Address - Zip Code:31510-2908
Mailing Address - Country:US
Mailing Address - Phone:912-632-2952
Mailing Address - Fax:912-632-8682
Practice Address - Street 1:1406 HABERSHAM DR
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-5306
Practice Address - Country:US
Practice Address - Phone:912-287-1130
Practice Address - Fax:912-287-9114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-25
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1336560952OtherGROUP NPI