Provider Demographics
NPI:1184651523
Name:SOUTHERN OTOLOGIC CLINIC PC
Entity Type:Organization
Organization Name:SOUTHERN OTOLOGIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:MORETZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:706-724-0668
Mailing Address - Street 1:818 SAINT SEBASTIAN WAY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2651
Mailing Address - Country:US
Mailing Address - Phone:706-724-0668
Mailing Address - Fax:706-724-1124
Practice Address - Street 1:818 SAINT SEBASTIAN WAY
Practice Address - Street 2:SUITE 204
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2651
Practice Address - Country:US
Practice Address - Phone:706-724-0668
Practice Address - Fax:706-724-1124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA24465207YX0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & NeurotologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAB04449Medicare UPIN