Provider Demographics
NPI:1528049046
Name:SOUTH GEORGIA MEDICAL CENTER INC
Entity type:Organization
Organization Name:SOUTH GEORGIA MEDICAL CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:W
Authorized Official - Last Name:HODGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-259-4140
Mailing Address - Street 1:PO BOX 1805
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31603-1805
Mailing Address - Country:US
Mailing Address - Phone:229-433-7150
Mailing Address - Fax:229-433-8416
Practice Address - Street 1:2501 N PATTERSON ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1735
Practice Address - Country:US
Practice Address - Phone:229-249-4144
Practice Address - Fax:229-249-4145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008065333600000X
3336S0011X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003225227AMedicaid
GA008065OtherSTATE LICENSE NUMBER
GA1143510OtherNCPDP NUMBER
GA008065OtherSTATE LICENSE NUMBER