Provider Demographics
NPI:1205840105
Name:STATESBORO CARDIOLOGY, PC
Entity Type:Organization
Organization Name:STATESBORO CARDIOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-489-6246
Mailing Address - Street 1:5 GRADY JOHNSON RD
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-6026
Mailing Address - Country:US
Mailing Address - Phone:912-489-6843
Mailing Address - Fax:912-489-3125
Practice Address - Street 1:5 GRADY JOHNSON RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-6026
Practice Address - Country:US
Practice Address - Phone:912-489-6843
Practice Address - Fax:912-489-6346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300033286AMedicaid
GAF40194Medicare UPIN
GA300033286AMedicaid