Provider Demographics
NPI:1861797474
Name:SOUTH GEORGIA HEALTH GROUP LLC
Entity type:Organization
Organization Name:SOUTH GEORGIA HEALTH GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-259-9962
Mailing Address - Street 1:814 NORTHWOOD PARK DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1398
Mailing Address - Country:US
Mailing Address - Phone:229-259-9962
Mailing Address - Fax:229-259-9941
Practice Address - Street 1:3215 N OAK STREET EXT STE D
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-7439
Practice Address - Country:US
Practice Address - Phone:229-259-9962
Practice Address - Fax:229-259-9941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041178332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies