Provider Demographics
NPI:1144454059
Name:SOUTH GEORGIA VASCULAR CLINIC
Entity type:Organization
Organization Name:SOUTH GEORGIA VASCULAR CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-353-6146
Mailing Address - Street 1:901 18TH ST E
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3648
Mailing Address - Country:US
Mailing Address - Phone:229-382-9733
Mailing Address - Fax:229-387-6161
Practice Address - Street 1:901 18TH ST E
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3648
Practice Address - Country:US
Practice Address - Phone:229-382-9733
Practice Address - Fax:229-387-6161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0314662086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1003883612OtherNPI/WILLIAM KAISER, MD
GA1154356889OtherNPI/BRAD HOLT PA
GA205810921CMedicaid
GA205810921CMedicaid
GAHOSP29Medicare PIN