Provider Demographics
NPI:1043533896
Name:MIT AMBULATORY CARE CENTER
Entity Type:Organization
Organization Name:MIT AMBULATORY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-925-1905
Mailing Address - Street 1:PO BOX 13663
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31416-0663
Mailing Address - Country:US
Mailing Address - Phone:912-691-0333
Mailing Address - Fax:912-691-1030
Practice Address - Street 1:149 RIVERWALK BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936-8190
Practice Address - Country:US
Practice Address - Phone:912-691-0333
Practice Address - Fax:912-691-1030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-09
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3755Medicare PIN