Provider Demographics
NPI:1861676892
Name:SOUTHERN UROLOGICAL ASSOCIATES
Entity Type:Organization
Organization Name:SOUTHERN UROLOGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACEK
Authorized Official - Middle Name:T
Authorized Official - Last Name:SOSNOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-316-2990
Mailing Address - Street 1:2805 N OAK ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-5922
Mailing Address - Country:US
Mailing Address - Phone:229-316-2990
Mailing Address - Fax:229-259-9547
Practice Address - Street 1:2805 N OAK ST
Practice Address - Street 2:SUITE B
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-5922
Practice Address - Country:US
Practice Address - Phone:229-316-2990
Practice Address - Fax:229-259-9547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058647174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF06546Medicare UPIN