Provider Demographics
NPI:1528126182
Name:SOUTH GEORGIA MEDICINE, P.C.
Entity type:Organization
Organization Name:SOUTH GEORGIA MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:VICKERS
Authorized Official - Last Name:CARRINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-382-9338
Mailing Address - Street 1:1111 20TH ST E
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3689
Mailing Address - Country:US
Mailing Address - Phone:229-382-9338
Mailing Address - Fax:229-382-4282
Practice Address - Street 1:1111 20TH ST E
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3689
Practice Address - Country:US
Practice Address - Phone:229-382-9338
Practice Address - Fax:229-382-4282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021582207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300029134AMedicaid
GACA5040OtherRAILROAD MEDICARE
GA1023084000OtherBCBS
GA11D090618OtherCLIA