Basic Information
| Provider Information | |||||||||
| NPI: | 1831241660 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUMMERVILLE WOMEN'S MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 WRIGHTSBORO RD | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309046220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067373948 | ||||||||
| FaxNumber: | 7067374035 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 WRIGHTSBORO RD | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309046220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067373948 | ||||||||
| FaxNumber: | 7067374035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 12/07/2012 | ||||||||
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| AuthorizedOfficialLastName: | FLANDERS | ||||||||
| AuthorizedOfficialFirstName: | CECELIA | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | INSURANCE ADMIN | ||||||||
| AuthorizedOfficialTelephone: | 7067373948 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | CMC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | GPA647 | 05 | SC | MEDICAID |