Provider Demographics
NPI:1013535657
Name:STATESBORO MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:STATESBORO MEDICAL GROUP, LLC
Other - Org Name:STATESBORO URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SREEVALLI
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-259-9474
Mailing Address - Street 1:106 IRONGATE PL
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-9173
Mailing Address - Country:US
Mailing Address - Phone:912-531-7338
Mailing Address - Fax:
Practice Address - Street 1:1176 BRAMPTON AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0847
Practice Address - Country:US
Practice Address - Phone:912-259-9474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-09
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1023247723OtherNPI
GA1023247731OtherNPI