Provider Demographics
NPI:1396763256
Name:SOUTH GEORGIA REGIONAL ANESTHESIA, PC
Entity type:Organization
Organization Name:SOUTH GEORGIA REGIONAL ANESTHESIA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-671-2019
Mailing Address - Street 1:PO BOX 3267
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31604-3267
Mailing Address - Country:US
Mailing Address - Phone:229-219-0350
Mailing Address - Fax:229-219-0349
Practice Address - Street 1:4280 N VALDOSTA RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-6814
Practice Address - Country:US
Practice Address - Phone:229-219-0350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4044Medicare ID - Type Unspecified