Provider Demographics
NPI:1497907935
Name:STATESBORO NEUROSURGERY, LLC
Entity Type:Organization
Organization Name:STATESBORO NEUROSURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEUROSURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:V
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:912-871-7777
Mailing Address - Street 1:1211 MERCHANT WAY STE 401
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0867
Mailing Address - Country:US
Mailing Address - Phone:912-871-7777
Mailing Address - Fax:912-871-7172
Practice Address - Street 1:1211 MERCHANT WAY STE 401
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0867
Practice Address - Country:US
Practice Address - Phone:912-871-7777
Practice Address - Fax:912-871-7172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057629207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA897954893AMedicaid
GA897954893AMedicaid
GA14BDHLGMedicare PIN