Provider Demographics
NPI:1356619613
Name:STATESBORO AMBULATORY SURGERY CENTER, INC
Entity type:Organization
Organization Name:STATESBORO AMBULATORY SURGERY CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:CUSHNER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:912-489-8727
Mailing Address - Street 1:95 BEL AIR DR
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30461-6879
Mailing Address - Country:US
Mailing Address - Phone:912-489-6519
Mailing Address - Fax:912-764-7882
Practice Address - Street 1:95 BEL AIR DRIVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30461
Practice Address - Country:US
Practice Address - Phone:912-489-6519
Practice Address - Fax:912-764-7882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GRP4317OtherPROVIDER TRANSACTION ACCESS NUMBER
GA000624896AMedicaid
GRP4317OtherPROVIDER TRANSACTION ACCESS NUMBER