Basic Information
| Provider Information | |||||||||
| NPI: | 1295266955 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEMORIAL SATILLA SPECIALISTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1921 ALICE ST STE B | ||||||||
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| City: | WAYCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315016200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124900722 | ||||||||
| FaxNumber: | 9124907227 | ||||||||
| Practice Location | |||||||||
| Address1: | 1921 ALICE ST STE B | ||||||||
| Address2: | |||||||||
| City: | WAYCROSS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315016200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124900722 | ||||||||
| FaxNumber: | 9124907227 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2017 | ||||||||
| LastUpdateDate: | 03/24/2017 | ||||||||
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| AuthorizedOfficialLastName: | FAILE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | ALI | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 8439567923 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | III | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.