Provider Demographics
NPI:1962538850
Name:SOUTHEASTERN UROLOGY ASSOCIATES
Entity type:Organization
Organization Name:SOUTHEASTERN UROLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:W
Authorized Official - Middle Name:WINSTON
Authorized Official - Last Name:WILFONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-742-5331
Mailing Address - Street 1:380 HOSPITAL DR
Mailing Address - Street 2:STE 320
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-8001
Mailing Address - Country:US
Mailing Address - Phone:478-742-5331
Mailing Address - Fax:478-750-1387
Practice Address - Street 1:380 HOSPITAL DR
Practice Address - Street 2:STE 320
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-8001
Practice Address - Country:US
Practice Address - Phone:478-742-5331
Practice Address - Fax:478-750-1387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA340005163OtherRR MEDICARE-WILFONG
GA340007314OtherRR MEDICARE PATTERSON
GACL8455OtherRR MEDICARE GRP #
GACL8455OtherRR MEDICARE GRP #
GA340005163OtherRR MEDICARE-WILFONG
GA34BDDQCMedicare PIN
GA340007314OtherRR MEDICARE PATTERSON
GA258968966AMedicare PIN