Provider Demographics
NPI:1336560952
Name:SOUTH GEORGIA PHYSICIANS GROUP, LLC
Entity Type:Organization
Organization Name:SOUTH GEORGIA PHYSICIANS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:CRAWFORD
Authorized Official - Last Name:DUBOSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-632-8961
Mailing Address - Street 1:204 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:GA
Mailing Address - Zip Code:31510-2908
Mailing Address - Country:US
Mailing Address - Phone:912-632-0314
Mailing Address - Fax:912-632-2554
Practice Address - Street 1:204 E 15TH ST
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:GA
Practice Address - Zip Code:31510
Practice Address - Country:US
Practice Address - Phone:912-632-0314
Practice Address - Fax:912-632-2554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-27
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003144050AMedicaid
GA861443280AMedicaid