Provider Demographics
NPI:1174835599
Name:SOUTH GEORGIA SPINE AND JOINT CENTER, LLC
Entity Type:Organization
Organization Name:SOUTH GEORGIA SPINE AND JOINT CENTER, LLC
Other - Org Name:SOUTH GEORGIA SPINE AND JOINT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:WALDROP
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:229-377-1392
Mailing Address - Street 1:26 3RD AVE NW
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39828-2000
Mailing Address - Country:US
Mailing Address - Phone:229-377-1392
Mailing Address - Fax:229-377-4448
Practice Address - Street 1:26 3RD AVE NW
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39828-2000
Practice Address - Country:US
Practice Address - Phone:229-377-1392
Practice Address - Fax:229-377-4448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6405060002Medicare NSC