Provider Demographics
NPI:1033282231
Name:SOUTH GEORGIA UROLOGY GROUP, P. C.
Entity Type:Organization
Organization Name:SOUTH GEORGIA UROLOGY GROUP, P. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-228-5500
Mailing Address - Street 1:PO BOX 1679
Mailing Address - Street 2:P. O. BOX 1679
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31799-1679
Mailing Address - Country:US
Mailing Address - Phone:229-228-5500
Mailing Address - Fax:229-226-5787
Practice Address - Street 1:116 MIMOSA DR
Practice Address - Street 2:SUITE 2
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6605
Practice Address - Country:US
Practice Address - Phone:229-228-5500
Practice Address - Fax:229-226-5787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300032989AMedicaid
GA300027790CMedicaid
GAGRP197Medicare PIN