Provider Demographics
NPI:1073728937
Name:EAST GEORGIA ORTHOPEDIC CENTER, PC.
Entity Type:Organization
Organization Name:EAST GEORGIA ORTHOPEDIC CENTER, PC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-871-6742
Mailing Address - Street 1:1601 FAIR RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-1698
Mailing Address - Country:US
Mailing Address - Phone:912-871-2563
Mailing Address - Fax:
Practice Address - Street 1:1601 FAIR RD
Practice Address - Street 2:SUITE 300
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-1698
Practice Address - Country:US
Practice Address - Phone:912-871-2563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty