Provider Demographics
NPI:1770815250
Name:SOUTH GEORGIA SPINE AND JOINT CENTER, LLC
Entity type:Organization
Organization Name:SOUTH GEORGIA SPINE AND JOINT CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:WALDROP
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:229-226-1035
Mailing Address - Street 1:202 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-5479
Mailing Address - Country:US
Mailing Address - Phone:229-226-1035
Mailing Address - Fax:229-226-3378
Practice Address - Street 1:202 S MADISON ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5479
Practice Address - Country:US
Practice Address - Phone:229-226-1035
Practice Address - Fax:229-226-3378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-08
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6405060001Medicare NSC