Provider Demographics
NPI:1881874105
Name:STATESBORO ONCOLOGY ASSOC.
Entity type:Organization
Organization Name:STATESBORO ONCOLOGY ASSOC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:B
Authorized Official - Last Name:HAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-764-3037
Mailing Address - Street 1:PO BOX 933946
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-3946
Mailing Address - Country:US
Mailing Address - Phone:770-693-2622
Mailing Address - Fax:770-693-6039
Practice Address - Street 1:27 LESTER RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-4764
Practice Address - Country:US
Practice Address - Phone:912-764-3037
Practice Address - Fax:912-764-3829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029-0007174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE51822Medicare UPIN
GRP 187Medicare PIN
GAD62370Medicare UPIN
GAE75201Medicare UPIN