Basic Information
| Provider Information | |||||||||
| NPI: | 1700054327 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH GEORGIA ANESTHESIA SPECIALISTS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8846 | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274190846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365531659 | ||||||||
| FaxNumber: | 3365533994 | ||||||||
| Practice Location | |||||||||
| Address1: | 4280 N VALDOSTA RD | ||||||||
| Address2: | ANESTHESIA DEPARTMENT | ||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 316026814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2296712000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2008 | ||||||||
| LastUpdateDate: | 05/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | POTYONDY | ||||||||
| AuthorizedOfficialFirstName: | LEWIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2296712000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 042441559A | 05 | GA | MEDICAID |