Provider Demographics
NPI:1508150509
Name:GEORGIA SURGICARE
Entity Type:Organization
Organization Name:GEORGIA SURGICARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:IBIKUNLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-466-6760
Mailing Address - Street 1:367 ATHENS HWY
Mailing Address - Street 2:BUILDING 100 SUITE 100A
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-2204
Mailing Address - Country:US
Mailing Address - Phone:678-466-6760
Mailing Address - Fax:678-802-7094
Practice Address - Street 1:367 ATHENS HWY
Practice Address - Street 2:BUILDING 100 SUITE 100A
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-2204
Practice Address - Country:US
Practice Address - Phone:678-466-6760
Practice Address - Fax:678-802-7094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-07
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
202G708170Medicare PIN