Provider Demographics
NPI:1770544694
Name:SOUTH GEORGIA SURGICAL CLINIC PC
Entity type:Organization
Organization Name:SOUTH GEORGIA SURGICAL CLINIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-382-9733
Mailing Address - Street 1:1007 GREENFIELD DR
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3795
Mailing Address - Country:US
Mailing Address - Phone:229-382-9733
Mailing Address - Fax:229-387-6161
Practice Address - Street 1:1007 GREENFIELD DR
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3795
Practice Address - Country:US
Practice Address - Phone:229-382-9733
Practice Address - Fax:229-387-6161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX ID NUMBER