Provider Demographics
NPI:1801078381
Name:EAST GEORGIA UROLOGIC CLINIC, PC
Entity type:Organization
Organization Name:EAST GEORGIA UROLOGIC CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:R
Authorized Official - Last Name:THALLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-764-9001
Mailing Address - Street 1:614 EAST GRADY STREET
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458
Mailing Address - Country:US
Mailing Address - Phone:912-764-9001
Mailing Address - Fax:912-764-3166
Practice Address - Street 1:614 E GRADY ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-2067
Practice Address - Country:US
Practice Address - Phone:912-764-9001
Practice Address - Fax:912-764-3166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046818208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty