Provider Demographics
NPI:1407907389
Name:SY, JOHNNY (DO)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:SY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 WATERS AVE
Mailing Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6220
Mailing Address - Country:US
Mailing Address - Phone:912-350-8113
Mailing Address - Fax:
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-350-8113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO1082207P00000X
GA58826207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA633234877COtherPEACHSTATE
GA393120OtherWELLCARE
GA633234877CMedicaid
SCG58826Medicaid
GA01062450OtherAMERIGROUP
SCG58826Medicaid
GA93BFDVNMedicare PIN