Provider Demographics
NPI:1083753404
Name:THE WIREGRASS MEDICAL & SURGICAL GROUP INC
Entity Type:Organization
Organization Name:THE WIREGRASS MEDICAL & SURGICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:CLANTON
Authorized Official - Last Name:MASSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-524-2706
Mailing Address - Street 1:804 N WILEY AVE
Mailing Address - Street 2:
Mailing Address - City:DONALSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:39845-1120
Mailing Address - Country:US
Mailing Address - Phone:229-524-2706
Mailing Address - Fax:229-524-1272
Practice Address - Street 1:804 N WILEY AVE
Practice Address - Street 2:
Practice Address - City:DONALSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:39845-1120
Practice Address - Country:US
Practice Address - Phone:229-524-2706
Practice Address - Fax:229-524-1272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051586207Q00000X
GA033591207R00000X
GA9288208600000X
GA019644208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP8001OtherMEDICARE GROUP NUMBER
GAGRP8001OtherMEDICARE GROUP NUMBER