Provider Demographics
NPI:1659327294
Name:STATESBORO ENT SURGICAL CENTER
Entity Type:Organization
Organization Name:STATESBORO ENT SURGICAL CENTER
Other - Org Name:STATESBORO ENT SURGICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:CREWS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-764-8200
Mailing Address - Street 1:106 PROCTOR ST
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-1351
Mailing Address - Country:US
Mailing Address - Phone:912-764-8200
Mailing Address - Fax:912-489-2954
Practice Address - Street 1:106 PROCTOR ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-1351
Practice Address - Country:US
Practice Address - Phone:912-764-8200
Practice Address - Fax:912-489-2954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024663261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical