Provider Demographics
NPI:1457377731
Name:SOUTH GEORGIA CARDIOLOGY
Entity Type:Organization
Organization Name:SOUTH GEORGIA CARDIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESEDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:TRI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-245-1000
Mailing Address - Street 1:2301 N ASHLEY ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2620
Mailing Address - Country:US
Mailing Address - Phone:229-245-1000
Mailing Address - Fax:229-242-2788
Practice Address - Street 1:2301 N ASHLEY ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2620
Practice Address - Country:US
Practice Address - Phone:229-245-1000
Practice Address - Fax:229-242-2788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038991174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00972353AMedicaid
GA00972353AMedicaid