Provider Demographics
NPI:1952412413
Name:SOUTH GEORGIA SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:SOUTH GEORGIA SURGERY CENTER, LLC
Other - Org Name:SOUTH GEORGIA SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:LUPI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:912-267-9000
Mailing Address - Street 1:306 ISABELLA STREET
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-3636
Mailing Address - Country:US
Mailing Address - Phone:912-267-9000
Mailing Address - Fax:912-267-9028
Practice Address - Street 1:306 ISABELLA STREET
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-3636
Practice Address - Country:US
Practice Address - Phone:912-490-7246
Practice Address - Fax:912-490-7247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA111252ASCA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00188566OtherRR MEDICARE
GA495658553AMedicaid
GA111252ASCAMedicare PIN