Provider Demographics
NPI:1033324629
Name:OGEECHEE OBGYN, P.C.
Entity Type:Organization
Organization Name:OGEECHEE OBGYN, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:K
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-871-6206
Mailing Address - Street 1:1310 BRAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0851
Mailing Address - Country:US
Mailing Address - Phone:912-871-6206
Mailing Address - Fax:
Practice Address - Street 1:1310 BRAMPTON AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0851
Practice Address - Country:US
Practice Address - Phone:912-871-6206
Practice Address - Fax:912-681-8558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300019870AOtherMEDICAID GROUP
=========OtherTAX ID NUMBER
GAGRP1571Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER