Basic Information
Provider Information
NPI: 1265518849
EntityType: 2
ReplacementNPI:  
OrganizationName: SOUTHEAST GEORGIA ANESTHESIA LLC
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Mailing Information
Address1: PO BOX 18824
Address2:  
City: GREENSBORO
State: NC
PostalCode: 274198824
CountryCode: US
TelephoneNumber: 3365531659
FaxNumber: 3365533994
Practice Location
Address1: 410 DARLING AVE
Address2: ANESTHESIA DEPT
City: WAYCROSS
State: GA
PostalCode: 315015246
CountryCode: US
TelephoneNumber: 3365531659
FaxNumber: 3365533994
Other Information
ProviderEnumerationDate: 10/27/2006
LastUpdateDate: 11/30/2010
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: JOHNSON
AuthorizedOfficialFirstName: KEITH
AuthorizedOfficialMiddleName: R
AuthorizedOfficialTitleorPosition: MEMBER
AuthorizedOfficialTelephone: 3365531659
IsSoleProprietor:  
IsOrganizationSubpart: N
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AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207L00000X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansAnesthesiology 

ID Information
IDTypeStateIssuerDescription
999314012A05GA MEDICAID


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