Provider Demographics
NPI:1639381171
Name:GEORGIA PHYSICIAN SOUTH,PC
Entity type:Organization
Organization Name:GEORGIA PHYSICIAN SOUTH,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LAB SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BRICKLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-449-4426
Mailing Address - Street 1:120 CARTER AVE
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516
Mailing Address - Country:US
Mailing Address - Phone:912-449-4426
Mailing Address - Fax:912-449-1517
Practice Address - Street 1:120 CARTER AVE
Practice Address - Street 2:
Practice Address - City:BLACKSHEAR
Practice Address - State:GA
Practice Address - Zip Code:31516
Practice Address - Country:US
Practice Address - Phone:912-449-4426
Practice Address - Fax:912-449-1517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAX17811Medicare UPIN
GA69WBDHTMedicare ID - Type UnspecifiedLAB PROVIDER NUMBER