Provider Demographics
NPI:1225462864
Name:SOUTHERN HEALTH CARE OF GEORGIA
Entity Type:Organization
Organization Name:SOUTHERN HEALTH CARE OF GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BLACKMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-509-5920
Mailing Address - Street 1:2790 SANDY PLAINS RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-4373
Mailing Address - Country:US
Mailing Address - Phone:770-509-5920
Mailing Address - Fax:770-509-5922
Practice Address - Street 1:2790 SANDY PLAINS RD
Practice Address - Street 2:SUITE 202
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-4373
Practice Address - Country:US
Practice Address - Phone:770-509-5920
Practice Address - Fax:770-509-5922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-31
Last Update Date:2013-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty