Provider Demographics
NPI:1538166053
Name:SOUTHERN OB GYN AMBULATORY SURGERY CENTER, INC
Entity type:Organization
Organization Name:SOUTHERN OB GYN AMBULATORY SURGERY CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:229-241-2800
Mailing Address - Street 1:341 CONNELL RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1471
Mailing Address - Country:US
Mailing Address - Phone:229-241-2800
Mailing Address - Fax:229-242-2402
Practice Address - Street 1:341 CONNELL RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1471
Practice Address - Country:US
Practice Address - Phone:229-241-2800
Practice Address - Fax:229-242-2402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA092-272261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA111233ASCAMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER