Provider Demographics
NPI:1497330625
Name:SOUTHWELL AMBULATORY INC
Entity Type:Organization
Organization Name:SOUTHWELL AMBULATORY INC
Other - Org Name:SOUTHWELL PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-353-3397
Mailing Address - Street 1:410 CONNELL RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1898
Mailing Address - Country:US
Mailing Address - Phone:229-353-6889
Mailing Address - Fax:229-219-1631
Practice Address - Street 1:2922 N OAK ST STE C
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1885
Practice Address - Country:US
Practice Address - Phone:229-262-6819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-09
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty