Provider Demographics
NPI:1437356359
Name:VIDALIA OB GYN
Entity Type:Organization
Organization Name:VIDALIA OB GYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:RUTZ, JR.
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-538-1500
Mailing Address - Street 1:1707 MEADOWS LANE
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474
Mailing Address - Country:US
Mailing Address - Phone:912-538-1500
Mailing Address - Fax:912-538-1501
Practice Address - Street 1:1707 MEADOWS LANE
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474
Practice Address - Country:US
Practice Address - Phone:912-538-1500
Practice Address - Fax:912-538-1501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044832202C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical ExaminerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4037Medicare ID - Type Unspecified