Provider Demographics
NPI:1205000395
Name:SOUTH GEORGIA VENTURES INC
Entity Type:Organization
Organization Name:SOUTH GEORGIA VENTURES INC
Other - Org Name:SOUTH GEORGIA AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-263-8528
Mailing Address - Street 1:PO BOX 5028
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31643-5028
Mailing Address - Country:US
Mailing Address - Phone:229-263-8528
Mailing Address - Fax:229-263-4302
Practice Address - Street 1:301 S MADISON ST
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:GA
Practice Address - Zip Code:31643-1443
Practice Address - Country:US
Practice Address - Phone:229-263-8528
Practice Address - Fax:229-263-4302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037-02341600000X, 3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA902019452AMedicaid
GA511G590009Medicare PIN