Provider Demographics
NPI:1003821786
Name:VALDOSTA WOMENS HEALTH CENTER PC
Entity Type:Organization
Organization Name:VALDOSTA WOMENS HEALTH CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:COURSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-333-0277
Mailing Address - Street 1:PO BOX 2130
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31604-2130
Mailing Address - Country:US
Mailing Address - Phone:229-333-0277
Mailing Address - Fax:229-241-1608
Practice Address - Street 1:604 E PARK AVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-3060
Practice Address - Country:US
Practice Address - Phone:229-333-0277
Practice Address - Fax:229-241-1608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA055002367AMedicaid
GAGRP2129Medicare UPIN