Provider Demographics
NPI:1538421177
Name:WAYNE SJC MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:WAYNE SJC MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:P
Authorized Official - Last Name:IERARDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-427-7790
Mailing Address - Street 1:320 PEACHTREE ST
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545-0244
Mailing Address - Country:US
Mailing Address - Phone:912-427-7790
Mailing Address - Fax:912-427-7707
Practice Address - Street 1:320 PEACHTREE ST
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0244
Practice Address - Country:US
Practice Address - Phone:912-427-7790
Practice Address - Fax:912-427-7707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-11
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA272895969CMedicaid
GA003127436AMedicaid
GA202G707585Medicare UPIN