Provider Demographics
NPI:1720693047
Name:SOUTHWELL AMBULATORY INC
Entity Type:Organization
Organization Name:SOUTHWELL AMBULATORY INC
Other - Org Name:SOUTHWELL OB/GYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-353-3397
Mailing Address - Street 1:410 CONNELL RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1898
Mailing Address - Country:US
Mailing Address - Phone:229-353-6889
Mailing Address - Fax:229-247-1084
Practice Address - Street 1:814 NORTHWOOD PARK DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1398
Practice Address - Country:US
Practice Address - Phone:229-262-6810
Practice Address - Fax:229-353-4901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-14
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty