Provider Demographics
NPI:1285662866
Name:STATESBORO UROLOGIC CLINIC, PC
Entity Type:Organization
Organization Name:STATESBORO UROLOGIC CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:TILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-764-6808
Mailing Address - Street 1:412 NORTHSIDE DR E
Mailing Address - Street 2:SUITE 500
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-4802
Mailing Address - Country:US
Mailing Address - Phone:912-764-6808
Mailing Address - Fax:912-764-2436
Practice Address - Street 1:412 NORTHSIDE DR E
Practice Address - Street 2:SUITE 500
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-4802
Practice Address - Country:US
Practice Address - Phone:912-764-6808
Practice Address - Fax:912-764-2436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020839208800000X
GA046818208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP694Medicare ID - Type Unspecified