Provider Demographics
NPI:1225262165
Name:GENERAL SURGERY OF MIDDLE GEORGIA, LLC
Entity Type:Organization
Organization Name:GENERAL SURGERY OF MIDDLE GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:H
Authorized Official - Last Name:MANN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:478-448-4949
Mailing Address - Street 1:PO BOX 4128
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-4128
Mailing Address - Country:US
Mailing Address - Phone:478-448-4949
Mailing Address - Fax:478-448-4435
Practice Address - Street 1:1111 GRIFFIN AVE
Practice Address - Street 2:SUITE 1A
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-9101
Practice Address - Country:US
Practice Address - Phone:478-448-4949
Practice Address - Fax:478-448-4435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA26591208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty