Provider Demographics
NPI:1548329410
Name:DIGESTIVE DISEASE CENTER OF SOUTH GEORGIA, PC
Entity type:Organization
Organization Name:DIGESTIVE DISEASE CENTER OF SOUTH GEORGIA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:G
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-227-0045
Mailing Address - Street 1:112 MIMOSA DR
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-6605
Mailing Address - Country:US
Mailing Address - Phone:229-227-0045
Mailing Address - Fax:229-227-9120
Practice Address - Street 1:112 MIMOSA DR
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6605
Practice Address - Country:US
Practice Address - Phone:229-227-0045
Practice Address - Fax:229-227-9120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-07
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021540174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4979Medicare PIN