Provider Demographics
NPI:1811286271
Name:SCOTT J WAGUESPACK MD/FAMILY HEALTHCARE
Entity type:Organization
Organization Name:SCOTT J WAGUESPACK MD/FAMILY HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:WAGUESPACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-375-2884
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:GA
Mailing Address - Zip Code:31539-0068
Mailing Address - Country:US
Mailing Address - Phone:912-375-2884
Mailing Address - Fax:912-375-2894
Practice Address - Street 1:11 CROSS ST
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:GA
Practice Address - Zip Code:31539-6427
Practice Address - Country:US
Practice Address - Phone:912-375-2884
Practice Address - Fax:912-375-2894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-06
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA063014174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF90431Medicare UPIN