Provider Demographics
NPI:1407802788
Name:ENT SURGICAL CENTER OF CENTRAL GEORGIA, INC
Entity Type:Organization
Organization Name:ENT SURGICAL CENTER OF CENTRAL GEORGIA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAIN
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:TOLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:478-923-0106
Mailing Address - Street 1:1719 RUSSELL PKWY
Mailing Address - Street 2:BLDG 300, SUITE 301
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-5763
Mailing Address - Country:US
Mailing Address - Phone:478-923-0106
Mailing Address - Fax:478-922-5211
Practice Address - Street 1:1719 RUSSELL PKWY
Practice Address - Street 2:BLDG 300, SUITE 301
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-5763
Practice Address - Country:US
Practice Address - Phone:478-923-0106
Practice Address - Fax:478-922-5211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA076116261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA111091ASCAMedicare ID - Type UnspecifiedMEDICARE FACILITY PROV #