Provider Demographics
NPI:1487180709
Name:SOUTH GEORGIA CENTER FOR CANCER CARE, LLC
Entity Type:Organization
Organization Name:SOUTH GEORGIA CENTER FOR CANCER CARE, LLC
Other - Org Name:SOUTH GEORGIA CENTER FOR CANCER CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STUART
Authorized Official - Middle Name:M
Authorized Official - Last Name:BITTING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-783-1253
Mailing Address - Street 1:104 WOODMONT BLVD STE 500
Mailing Address - Street 2:CREDENTIALING DEPT.
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-2245
Mailing Address - Country:US
Mailing Address - Phone:615-783-1254
Mailing Address - Fax:615-783-1082
Practice Address - Street 1:27 COACH LEE HILL BLVD.
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-4764
Practice Address - Country:US
Practice Address - Phone:912-764-3037
Practice Address - Fax:912-764-3829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-05
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANONE261QX0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003116257AMedicaid
GAPENDINGMedicare PIN