Provider Demographics
NPI:1164188413
Name:SKIDAWAY MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:SKIDAWAY MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-201-1140
Mailing Address - Street 1:310 EISENHOWER DR STE 12A
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-2632
Mailing Address - Country:US
Mailing Address - Phone:912-201-1140
Mailing Address - Fax:
Practice Address - Street 1:310 EISENHOWER DR STE 12A
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-2632
Practice Address - Country:US
Practice Address - Phone:912-201-1140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SKIDAWAY MEDICAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care