Provider Demographics
NPI:1104038058
Name:SOUTH GEORGIA UROLOGY CLINIC, P.C.
Entity Type:Organization
Organization Name:SOUTH GEORGIA UROLOGY CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:REX
Authorized Official - Middle Name:O
Authorized Official - Last Name:AJAYI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-435-0832
Mailing Address - Street 1:P.O. BOX 72108
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31708
Mailing Address - Country:US
Mailing Address - Phone:229-435-0832
Mailing Address - Fax:229-435-2857
Practice Address - Street 1:803 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701
Practice Address - Country:US
Practice Address - Phone:229-435-0832
Practice Address - Fax:229-435-2857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADG1080OtherRAILROAD MEDICARE
GA00279518AMedicaid
GAGRP3903Medicare PIN