Provider Demographics
NPI:1134367550
Name:VIDALIA ORTHOPEDIC CENTER, LLC
Entity type:Organization
Organization Name:VIDALIA ORTHOPEDIC CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:M
Authorized Official - Last Name:OSTEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-538-5314
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0407
Mailing Address - Country:US
Mailing Address - Phone:912-538-0040
Mailing Address - Fax:912-538-8133
Practice Address - Street 1:1707 MEADOWS LN
Practice Address - Street 2:SUITE H
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-7200
Practice Address - Country:US
Practice Address - Phone:912-538-0040
Practice Address - Fax:912-538-8133
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST REGIONAL PRIMARY CARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-22
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA333690169CMedicaid
GA489633273AMedicaid
GA333690169BMedicaid
GA333690169CMedicaid