Provider Demographics
NPI:1225023021
Name:ARC OF GEORGIA, LLC
Entity Type:Organization
Organization Name:ARC OF GEORGIA, LLC
Other - Org Name:PREMIER SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5900
Mailing Address - Street 1:3243 GLYNN AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4851
Mailing Address - Country:US
Mailing Address - Phone:912-264-9029
Mailing Address - Fax:912-264-1085
Practice Address - Street 1:3243 GLYNN AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4851
Practice Address - Country:US
Practice Address - Phone:912-264-9029
Practice Address - Fax:912-264-1085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-18
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAK826642261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000828517AMedicaid
GA111002ASCAMedicare ID - Type UnspecifiedMEDICARE PROVIDER ID