Provider Demographics
NPI:1598827974
Name:MEDICAL SOUTH PC
Entity Type:Organization
Organization Name:MEDICAL SOUTH PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROMULO
Authorized Official - Middle Name:PEREZ
Authorized Official - Last Name:NAVARRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-384-5832
Mailing Address - Street 1:PO BOX 1028
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31534-1028
Mailing Address - Country:US
Mailing Address - Phone:912-384-5832
Mailing Address - Fax:912-383-8279
Practice Address - Street 1:1309 OCILLA RD
Practice Address - Street 2:SUITE A
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2209
Practice Address - Country:US
Practice Address - Phone:912-384-5832
Practice Address - Fax:912-383-8279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023646208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD40738Medicare UPIN
GA02BBCRMMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER