Basic Information
| Provider Information | |||||||||
| NPI: | 1871600486 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WOMEN'S HEALTH GROUP SE GA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 418 EH COURT UNIT 4B | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9122670884 | ||||||||
| FaxNumber: | 9122677948 | ||||||||
| Practice Location | |||||||||
| Address1: | 418 EH COURT UNIT 4B | ||||||||
| Address2: | |||||||||
| City: | BRUNSWICK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9122670884 | ||||||||
| FaxNumber: | 9122677948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 02/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSTON | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9122670884 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0031447777A | 05 | GA | MEDICAID |