Provider Demographics
NPI:1952599730
Name:RENEWALMD STATESBORO
Entity Type:Organization
Organization Name:RENEWALMD STATESBORO
Other - Org Name:CEPS STATESBORO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PATIENT ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:KEEL
Authorized Official - Suffix:
Authorized Official - Credentials:CPC, CPB, CPRC
Authorized Official - Phone:912-920-5624
Mailing Address - Street 1:900 MOHAWK STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-1780
Mailing Address - Country:US
Mailing Address - Phone:912-920-5624
Mailing Address - Fax:912-920-7921
Practice Address - Street 1:1209 MERCHANT WAY
Practice Address - Street 2:SUITE 301
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458
Practice Address - Country:US
Practice Address - Phone:912-920-2090
Practice Address - Fax:912-920-7921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA48571208200000X
GA51685208200000X
GA45759208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG58998Medicare UPIN
GAF61332Medicare UPIN
GAH69912Medicare UPIN