Provider Demographics
NPI:1962614024
Name:SOUTHEAST GEORGIA RADIOLOGY
Entity type:Organization
Organization Name:SOUTHEAST GEORGIA RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:H
Authorized Official - Last Name:MANNING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-466-6170
Mailing Address - Street 1:3020 SHRINE RD
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520
Mailing Address - Country:US
Mailing Address - Phone:912-267-0533
Mailing Address - Fax:912-267-7313
Practice Address - Street 1:2000 DAN PROCTOR DR
Practice Address - Street 2:
Practice Address - City:ST MARYS
Practice Address - State:GA
Practice Address - Zip Code:31520
Practice Address - Country:US
Practice Address - Phone:912-466-6170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0114162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA04155OtherBCBS GA
GA343124Medicaid
GA343124Medicaid
GAGRP2502Medicare ID - Type Unspecified
GA04155OtherBCBS GA