Provider Demographics
NPI:1760627699
Name:STATTESBORO ORTHOPAEDIC CENTER, INC
Entity Type:Organization
Organization Name:STATTESBORO ORTHOPAEDIC CENTER, INC
Other - Org Name:COASTAL ORTHOPEDICS AND SPORTS MEDICINE SPECIALISTS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MD-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:TANKERSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-225-3760
Mailing Address - Street 1:1497 FAIR RD
Mailing Address - Street 2:STE 101
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0823
Mailing Address - Country:US
Mailing Address - Phone:912-225-3760
Mailing Address - Fax:912-225-3767
Practice Address - Street 1:1497 FAIR RD
Practice Address - Street 2:STE 101
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0823
Practice Address - Country:US
Practice Address - Phone:912-225-3760
Practice Address - Fax:912-225-3767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-05
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034484207X00000X, 207XS0114X
207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Single Specialty