Provider Demographics
NPI:1437299740
Name:SOUTH GA SPINE CARE INSTITUTE
Entity Type:Organization
Organization Name:SOUTH GA SPINE CARE INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:CORDISTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-890-6612
Mailing Address - Street 1:8 LIVE OAK CT
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-6783
Mailing Address - Country:US
Mailing Address - Phone:229-890-6612
Mailing Address - Fax:229-890-6621
Practice Address - Street 1:8 LIVE OAK CT
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6783
Practice Address - Country:US
Practice Address - Phone:229-890-6612
Practice Address - Fax:229-890-6621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051451207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000921522BMedicaid
GA20BBFNMMedicare ID - Type Unspecified
GA000921522BMedicaid