Provider Demographics
NPI:1558615096
Name:GEORGIA SOUTHERN UNIVERSITY
Entity Type:Organization
Organization Name:GEORGIA SOUTHERN UNIVERSITY
Other - Org Name:GEORGIA SOUTHERN UNIVERSITY ATHLETICS
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-536-2239
Mailing Address - Street 1:590 HERTY DRIVE
Mailing Address - Street 2:ROOM 1216
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458
Mailing Address - Country:US
Mailing Address - Phone:912-478-7581
Mailing Address - Fax:912-478-7690
Practice Address - Street 1:590 HERTY DRIVE
Practice Address - Street 2:ROOM 1216
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458
Practice Address - Country:US
Practice Address - Phone:912-478-7581
Practice Address - Fax:912-478-7690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health